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COUNTyDutchess
CITYiTOWN Wappinger
~~~~kCRT1368
~5~~J~R52
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Paul A. Waldbilliq
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
,1 II
'1' I,~ - {'J)
I
(Jill!;
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Brenda Passano
MIDDLE CURRENT SURNAME
~
A FULL NAME
11. A. FULL NAME
FIRST
"-
N
B BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Waldbillig
(OPTIONAL - SEE REVERSEh53-10-4221
D. SOCIAL SECURITY NUMBER U
12 RESIDENCE ANew York BDutchess
(STATE) (COUNTY)
C CHECK ONE D CITY ~ TOWN D VILLAGE
~~~ClFyWappinQer
D STREET ADDRESsS2 Tor Road
ZIP 12590
D YES"I'J NO
1974
YEAR
C SURNAME AFTER MARRIAGE
10PTIONAL. SEE REVERSE119-60-9231
D SOCIAL SECURITY NUMBER
2 RESIDENCE ANew York B. Dutchess
ISTATE) ..L (COUNTY)
C CHECK ONE D CITYLJ TOWN D VILLAGE
~~~CIFY Wappinger
o STREET ADDRESS 15 Alpert Drive ZIP 12590
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES"'D NO
/24 /197~
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13, A. AGF?7 13.B. DATE OF BIRTH 08 41
MONTH DAY
3 A AGE26
3B, DATE OF BIRTH
12
MONTH
4 EMPLOYMENT
A. USUAL OCCUPATION Actuary Analyst
B. TYPE OF INDUSTRY OR BUSINEssHewitt Associates
5. PLACE OF BIRTrPouQhkeepsie. New York
(CITY, STATE'COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINEssArlington Central School
15, PLACE OF BIRTcPouohkeeDsie: New York
(CIT:r"STATE/COITNTAY II- NOT USA)
16, FATHER
A, NAMEAlfred Passano
B. COUNTRY OF BIRTlU S A
17, MOTHER
A. MAIDEN NAME.lill S'Iierveld
B COUNTRY OF BIRTU S A
18. NUMBER OF THIS MARRIAGE 1
19, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
6. FATHER
A, NAME James Waldbillig
B. COUNTRY OF BIRTHU S A
7. MOTHER
A. MAIDEN NAME Norma Chiavelli
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW 010 LAST MARRIAGE END? (3) D DIVORCE
(3) D ANNULMENT
/ /
(2) D DEATH
B HOW DID LAST MARRIAGE END? (3) D DIVORCE
C DATE LAST MARRIAGE ENDED?
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(21 [J DEATH
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? DYES [J 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
D. ARE ANY FORMER SPOUSE(S) ALIVE? eYES D 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
1ST
2ND
3RD
D
D
D
D
D
D
o
D
D
21 SIGNATURE OF GROOM ~
22. SIGNATURE OF BRID
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23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York the bride and groom named above by any person authorized by New York Domestic
Relations Law 911 to perform marriage ceremonies wit n 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
{ } NAME (PRINT) Gloria J_ M r~e TIME MONTH YEAR MONTH YEAR
SEAL SIGNATURE ~
'-v-I ~fi~t~m~ljush 'Rd Wa 9:45 ~~ 5 09 2002 01 07 2002
ZIP
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A, STATE NEW YORK B. COUNTY Pw:1t'b
C LOCATION OF CEREMONY
(CHECjONE AND SPECIFY)
~Y OF D TOWN OF D VILLAGE OF
SPECIF;:p'{)(,f 1 h teef> Ie'
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Jul r r;., 20IJ 2-
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"-~D
NAME (PRINT)
SIGNATURE ~
