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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~'J'Ei'ln n RnQQ;';;ENT SURNAME
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law S11 to perform marriage ceremonies within 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
COUNTY Dutchess
CITYITOWN Wappinger
~~~~~~1' 1368
~5~I~J~R 35
A FULL NAME
FIRST
"-
N
B BiRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) nC4_"n -n 14?
o SOCIAL SECURITY NUMBER _::.1_ 00 - - --
2 RESiDENCE A. N Y B nl Jtr.hp.~~
(STATE) (COUNTY)
C CHECK ONE 0 CITY [Y'rOWN [J VILLAGE
AND
SPECIFY Wappinger
o STREET ADDRESS 24 Wildwood Drive
E is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
ZIP 12590
DYES c:Y'NO
3B. DATE OF BIRTH
3 A AGE 35
4. EMPLOYMENT
A USUAL OCCUPATION Flp.dmni~ A~~p.~~ Tp.~hnir.ian
B. TYPE OF INDUSTRY OR BUSINESS Rest Ac~ess Systems
5 PLACE OF BIRTH (ET~i~?A9E~!?u~~~IF e~~~sylvania
6. FATHER
MON
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A NAME Wi'lltp.r Rnoo~. .Ir
B COUNTRY OF BIRTH l J S A
7. MOTHER
A MAIDEN NAME Arlene Gontarek
B. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE ?
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
o
B HOW DID LAST MARRIAGE END? (3) D~IVORCE (3) 0 ANNULMENT
C DATE LAST MARRIAGE ENDED? 10/ n7 /
MONTH DAY
D ARE ANY FORMER SPOUSE(S) ALIVE? 0 "'ES 0 NO
10 IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DA TE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ntn7/1 ~~7 nlltchp!=:!=: r.rll mty. Npw 0
.. , York 0
o
(2) 0 DEATH
1~~7
YEAR
1ST
2ND
3RD
4TH
21 SIGNATURE OF GROOM ~
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{ SEAL }
'-y-I
NAME (PRINT)
I STATE FILE NUMBER I
(THIS SPACE FOR STA TE USE ONL Y)
{Jtl:ltt 5!:; /tvf
Lo SUPPLEMENTAL FILE -.l
11. A. FULL NAME
FROM THE BRIDE
, ;!=:i'I A Fngplhi'lrrlt
MIDDLE CURRENT SURNAME
FIRST
B BIRTH NAME (MAIDEN NAMEI, IF DIFFERENT
C SURNAME AFTER MARRIAGE Boggs
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER nRA-e;A-11R?
12 RESIDENCE A. N V nllkhp!=:~
(sf A TE) (COUNTY)
C. CHECK ONE 0 CITY 0 >lOWN 0 VILLAGE
AND W .
SPECIFY appmger
D. STREET ADDRESS 24 Wildwood Drive ZIP 12590
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES D"NO
13 A. AGE 35 138 DATE OF BIRTH MONQ~ / :?vB / 1~~6
14. EMPLOYMENT
A. USUAL OCCUPATION Hair Styli~t
B. TYPE OF INDUSTRY OR BUSINESS Europhoria
15. PLACE OF BIRTH Yonkers New York
(CITY, STATE/COUNTRY IF NOT USA)
16 FATHER
A. NAME ArthlJr Fngp.lhartit
8 COUNTRY OF BIRTH LJ S A
17. MOTHER
A. MAIDEN NAME Barbara Rubino
8 COUNTRY OF BIRTH II 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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
(31 0 ANNULMENT
/ /
MONTH DAY YEAR
D. 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
1ST
2ND
3RD
o 0
o 0
o 0
C 0
that no legal impedime t exists
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
08:41'M
PM
13
2
206
11 2002
04
CIVIL
28 PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNT~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY &x.t'{.h ,,5..1 te ttYl