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CQuNT'Putchess
CITYiTOWNWappinger
~~~~kCR1368
~5~I~J~R48
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Matthew J. Brandt
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
(lj!11,t
II
~-~/.t)1
_I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Dawn M. Yanazzo
~
1 A FULL NAME
11. A FULL NAME
FIRST
CURRENT SURNAME
CURRENT SURNAME
FIRST
MIDDLE
MIDDLE
B BIRTH NAME, IF DIFFERENT
BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Brandt
(OPTIONAL - SEE REVERSEOS3-70-2230
o SOCIAL SECURITY NUMBER
12 RESIDENCE "New York B Westchester
C CHECK ONE (STAgl CITY ~ TOWN C VILLAGE (COUNTY I
~~~CIF,Montrose
o STREET ADDRESP Scala Court
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEllI70-66-0191
o SOCIAL SECURITY NUMBER U
2 RESIDENCE ANew York B Dutchess
C CHECK ONE (STA~) CITY";D TOWN 0 VILLAGE (COUNTY)
~~~CIFY Wappinger
o STREET ADDRESs41 Sherwood Forest Apt. D ZIP 12590
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE' 0 YES"''b NO
AJ3 /1974
YEAR
ZIP10548
o YES'tJ NO
1974
YEAR
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE'
13 A, AGr2.1 13,B, DATE OF BIRTH 10 ~6
MONTH DA Y
3 A
AG~8
3B DATE OF BIRTH
04
MONTH
DAY
4 EMPLOYMENT
A, USUAL OCCUPATION Technician
B TYPE OF INDUSTRY OR BUSINESSI. B. M.
5 PLACE OF BIRTJ)anbury, Connecticut
(CITY, STATE."COUNTRY IF NOT USA)
14 EMPLOYMENT
A, USUAL occuPATlo~eQistered Nurse
B TYPE OF INDUSTRY OR BUSINESsVassar Brothers Hospital
15, PLACE OF BIRTJironx. New York
(CITY, STATE/COUNTRY IF NOT USA)
6 FATHER
A, NAME William Brandt
B. COUNTRY OF BIRTHU S A
16, FATHER
A, NAMcJoseph Yanazzo
B COUNTRY OF BIRTlJ S A
7 MOTHER
A, MAIDEN NAME Joanne Javenes
B, COUNTRY OF BIRTH USA
B NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
17, MOTHER
A, MAIDEN NAMESnphie Pi!':Rtik
B COUNTRY OF BIRTlJ S A
18. NUMBER OF THIS MARRIAGE 1
19, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END' (3 ::::J 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
/ /
(2) :J DEATH
MONTH DAY
D ARE ANY FORMER SPOUSE{S) ALIVE? 0 YES :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
YEAR
MONTH DAY
D ARE ANY FORMER SPOUSE{S) ALIVE? 0 YES C 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
YEAR
:J
1ST
2ND
3RD
4TH
hat the information I provided is tru
[J 0
c: 0
c: 0
o r:
nd that I declare that no legal impediment exists
w
w
go
UJ
o
o
21 SIGNATURE OF GROOM ~
22 SIGNATURE OF BRIDE ~
w
en
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...J
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Stat of the bride and groom named above by any person authorized
Relations Law S11 to perform marriage ceremonies within ew York State, THIS LICENSE VALID IN NEW YORK STATE ONLY,
::J 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
TIME YEAR
SEAL SIGNATURE ~
'-v-i !~~~ta~~liUSh Rd ZIP 1 :42 ;~
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICA TED
30 2002
by New York Domestic
25 B SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON
MONTH
DAY
YEAR
2002 06
10 CIVIL
28 PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~iy
o OTHER, SPECIFY
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
[J CITY OF C TOWN OF~ILLAGE OF
SPECIFY ~~~
-
~~~:~~~~~T ~ 4J ~t..~ ~~ \)R.lC II(c
SIGNATURE ~ ~ ~ - J ~
~~N~efi.q~ f.( Po s,.- Rob a\1C ~ ~
STREET CIT'Y TOWN
30 WITNESS TO CEREM
NAME (PRINT) G- L;
SIGNATURE ~
DOH-98 (11/98)
TITLE toe.. p~~
DATE ~Ir'! (~)..
~''1 IO~({
STATE ZIP
31 WITNESS TO CEREMONY
NAME (PRINT) <'l't~t..l' INe "'t IIH/ ~
SIGNATURE ~