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COUNT-Rutchess
CITY/TowJI'!'appinger
~~J~kCR1I368
~G~I~J~l46
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and )
CERTIFICATE OF Y'
MARRIAGE v
FROM THE GROOM
Randall D. Simoniette
I STATE FILE NUMBER
I (THIS SPACE FOR STATE USE ONL Yi
iJ~
I
Jr~ ~~Lf~1
L U SUPPLEMENTAL FILE
-.J
A FUll NAME
V FROM THE BRIDE
1 h FUll NAME Linda M" Diringer
v / FIRST MIDDLE CURRENT SURNAME
/ 8 BIRTH NAME (MAIDEN NAME)g. DIFFERE~~reg~.
C SURNAME AFTER MARRIAGE-::oimometle-dmnger
(OPTIONAL. SEE REVERSEfl7~50-9818
D SOCIAL SECURITY NUMBER U ~
12 RESIDENcEl"ew York BDutchess
C. CHECK ONE (STA~) CITY"D TOWN 0 VILLAGE (COUNTY)
AND W "
SPECIF'-. applnger
D STREET ADDRES?1 Daisy Lane
FIRST
MIDDLE
CL
N
8 BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL SEE REVERS561 96 8685
D SOCIAL SECURITY NUMBER --
2 RESIDENCE ANew York B Dutchess
(STATE) ~ (COUNTY)
C CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY Wappinger
D STREET ADDRES~'l Daisy Lane ZIP 12590
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VillAGE? 0 YES....O NO
",22 /1947
DAY YEAR
ZIP12590
o YEs'''b NO
tH54
3 A. AG~4
07
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE?
13. A. AG.ft7 13B DATE OF BIRTH 07 m
MONTH DA Y
3B. DATE OF BIRTH
YEAR
MONTH
4 EMPLOYMENT
A. USUAL OCCUPATIONBoat Buiider
B. TYPE OF INDUSTRY OR BUSINEs~toml King Marine Center
5. PLACE OF BIRT~av City. Michiqan
(CITY. STATE/COUNTRY IF NOT USA)
6 FATHER
A NAME Randall Simonielte
B COUNTRY OF BIRTJJ S A
7. MOTHER
A MAIDEN NAME Marietta Hardy
8. COUNTRY OF BIRTHU S A
NUMBER OF THIS MARRIAGE2
14. EMPLOYMENT
A. USUAL OCCUPATlmpurgical Dentai Assistant
B. TYPE OF INDUSTRY OR BUSINESJ:!r. Frank
15. PLACE OF BIRTPouqhkeepsie. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAM~ohn GreQa
B. COUNTRY OF BIRTU S A
17 MOTHER
A. MAIDEN NAMcElizabeth Spiegel
B. COUNTRY OF BIRM S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B HOW DID lAST MARRIAGE END? (3')'0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C DATE LAST MARRIAGE ENDED? 02 /24 /1994
MON~ DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 1] 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
1ST02f24/1994 Kingston. Np.w Yot1c 1J 0
2ND 0
3RD 0
4TH 0
I, being duly sworn, depose
as to my right to enter into the m
DEATH
..
I
DEATH
o
B. HOW DID lAST MARRIAGE END? (3) [J DIVORCE (3) [-j ANNULMENT (2) DEATH
C DATE LAST MARRIAGE ENDED? 03 / .18 /t 991
MONTH ...tDA Y YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES TJ 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
iJ
1ST 0
~D n
3RD 0
4TH 0 n
f that the information I provided is true and that I declare that no legal impediment exists
[J
21.
22 SIGNATURE OF BRIDE ~ '
23
authorized by New York Domestic
w
(/)
Z
W
()
:::i
TIME
MONTH
YEAR MONTH
YEAR
DATED4/29/2002
n e Falls NY 12590
C Y/r WN STATE ZIP
27. TYPE OF CEREMONY
AM
.t :13 PM 04
30
2002 06
28 2002
28. PLACE WHERE MARRIAGE CCURRED
o 0 RELIGIOUS
9 0 OTHER. SPECIFY
1 n CIVIL
RK B. COUNTY
A. STAT
TITLE
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF C TOWN OF 0 VILLAGE OF
SPECIFY
