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COUNTyDutchess
CITYiTOWN Wappinaer
~~~~~C~1368
~5~'~J~pS6
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Damon Bianchini
MIDDLE CURRENT SURNAME
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
I
a&n t
~. 1/ J tt ~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Chervl A Tompkins
MltOLE CURRENT SURNAME
~
A FULL NAME
11 A FULL NAME
FIRST
FIRST
Q.
;;
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C SURNAME AFTER MARRIAGE BiAnchini
(OPTiONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 112-6:7-744R
12 RESIDENCE ..New York BnlJtr.hp.~~
(STATE) ,COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
AND \AI .
SPECIFY" applngers 11::111 ~
o STREET ADDRES29 South Remsen Avenue zIP17S9n
E is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE' owtJ YES 0 NO
13 A. AGF23 13.8. DATE OF BIRTH Q1TH -1" 3DAy 147;~AR
14 EMPLOYMENT
A. USUAL OCCUPATlol'lNaitress
B TYPE OF INOUSTRY OR BUSINES:;GreenhslJm .\ Gilhnnley's
15. PLACE OF BIRT~eek~kill New Ynrk
(CITY. STATEleOUNTRY IF NOT USA)
16. FATHER
A. NAMEThomas Tompkins
B. COUNTRY OF BIRT~ J S A
17 MOTHER
A. MAIDEN NAMEJUdy Kinney
B COUNTRY OF BIRT(jJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MAP.RIAGE
(OPTIONAL. SEE REVERSQ,082 62-4168
o SOCIAL SECURITY NUMBER U -
2 RESIDENCE ANew York B Dutchess
{STATEI (COUNTY)
C CHECK ONE 0 CITY 0 TOWN"'b VILLAGE
~~~CIFY Wappinqers Falls
o STREET ADDRES~9 South Remsen Avenue
ZIP 12590
ootJ YES 0 NO
/1 Q77
YEAR
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE'
3 A AGF25 3B. DATE OF BIRTH 07 /1~
MONTH DAY
4 EMPLOYMENT
A USUAL OCCUPATION Sheet Metal Mechanic
B TYPE OF INDUSTRY OR BUSINEssCarey And Walsh
5. PLACE OF BIRTMount KiscoL New York
(CITY. STATE/CO UN THY IF NOT USA)
6 FATHER
A. NAME Dario Bianchini
B COUNTRY OF BIRTHlJ S A
7 MOTHER
A. MAIDEN NAME pl'lmelR n' Ericole
B COUNTRY OF BIRTH I J S A
8 NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
DEATH
n
n
o
o
B HOW DID LAST MA8RIAGE END' (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) [J DEATH
B HOW DID LAST MARRIAGE END' (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(21 '0 DEATH
MONTH DAY YEAR
o ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10 IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
o ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
w
en
z
w
u
:J
o 0 1 ST 0 ::J
o 0 2ND 0 C
o 0 3RD C 0
o 0 4TH 0 n
knowledge and belief that the information I provided is true and that I declare that no legal impMiment eXists
\
22 SIGNATURE OF BRIDE ~ f."'" \(\.(),.", \. 1 n tJ C'lN't\.n k N\ f):)
~ - ~US,~A~~~
23 ~~~~.r~~~D~NT~~~O~RN~~yBg~~~~E DATE 0~/1 nOnn?
This license authorizes the marriage in ate of the bride and groom named above by any person authorized by New York Domestic
Relations Law S11 to perform marriage ceremonies wit New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24 TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
1ST
2ND
3RD
4TH
I, being duly sworn, depose and S
as to my right to enter into the rr'
21 SIGNATURE OF GROOM ~
~
{ SEAL }
~
NAME (PRINT)
TIME
MONTH
DAY
YEAR
MONTH
YEAR
SIGNATURE ~
MAILING ADDRESS
20 Middl
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICA TED
AM
PM
5
11
2002 07
09 2002
3:00
ZIP
YTOWN
26. SOLEMNIZATION OCCURRED
TIME MO DAY YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY &CMI J.e.
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF rt TOWN OF C VILLAGE OF
J.){'v fA.); 1 ~ ?1/
o ~RELlGIOUS
9 [J OTHER. SPECIFY
10 CiVIL
b
3>
0;;"
SPECIFY
31 WITNESS T
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~