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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM T~~~rp?~~ile
Dutchess
COUNTY W .
upplrlglt:r
CITY/TOW)) 68
DISTRICTI.J
~~~,~~~F32
NUMBER
A FULL NAME
MIDDLE
CURRENT SURNAME
FIRST
0-
N
B BIRTH NAME, IF DIFFERENT
C s~~~~~JN'tLT~~~t:e~~s~J 28-66-4649
o SOCIAL SEj;IJRITY N~~BE1L 0' d "
New T OrK UlCI less
2 RESIDENCE A. (STATE) ..,. B. (COUNTY)
C ~~6CK oVvsPPihg~rh1.crrso VILLAGE
SPECIFY 15 High Slrlt:lt:l Apt. B 12590
o STREET ADDRESS ~
E IS R~~NCE WITHiN LIMITS OF CITY OR INCORPORATEiJ~LAGE? 111 0 YES .H:.~~
3 A AGE 3B. DATE OF BIRTH L ~
MONTH DAY YEAR
4. EMPLOYMENT S. 1M. t .
Igns sin siner
A. USUAL OCCUPATION M~lru Nurlh
B. TYPE OF IND~Tad~BUSINES)J .. rk
5. PLACE OF BIRTH 0 pnng, ew TO
(CITY, STATE/COUNTRY IF NOT USA)
6 FATHER Charles Nobile Jr.
A. NAME USA
B, COUNTRY OF BIRTH
7, MOTHER
Rosemarie Dillon
USA
B. COUNTRY OF BIRTH 1
8 NUMBER OF THIS MARRIAGE
A. MAIDEN NAME
9. PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVfiRCE CIVIL A~ULMENT
D'[tTH
B HOW DID LAST MARRIAGE END? 13} 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
13} 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D 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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
;:) I AI C rlL.1I:. f'tUMDI:.M
(THIS SPACE FOR STA TE USE ONL Y)
1Ji[
! /' ,1
/tJ ~~] "(J1
L 0 SUPPLEMENTAL FILE
~
11 A, FULL NAME
FROM THE-BBJDE ky
Amy-B: Pel(ars
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME),t\I~t;1reNT
C. S~~~~~JN~~E~~t~~e~~SE053-62-6535
o SOCIAL SlEi~~Tdrt Dutchess
12 RESIDENCE A, (STATE) .; B (COUNTY)
C ~~6CK 'WspphldeJ's CFaCfrs 0 VILLAGE
SPECIFY 15 Higt I Sit eel Apt. B
o STREET ADDRESS
12590
ijj
E. IS R~~NCE WITHIN LIMITS OF CITY OR INCORPORATfij~LLAGE? 74 0
13. A AGE 13.B. DATE OF BIRTH L
MONTH DAY
14. EMPLOYMENT Account Rep
A, USUAL OCCUPATION A d R I
~u It: uuut:y rlC.
s. TYPE OF IND~1fl'{gA.sIJ.SHSS r'-1 .. k
t'OU Keltif"SIIt: ...It:W Tor
15, PLACE OF BIRTH '
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER Arnold Pekarsky
A. NAME USA
S. COUNTRY OF BIRTH
Y1Y/iO
YEAR
17, MOTHER
Sheila Keller
A, MAIDEN NAME U ~ A
S. COUNTRY OF BIRTH 1
18, NUMBER OF THIS MARRIAGE
19, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
Dt)ORCE CIVIL A'trULMENT
D'(fTH
B, HOW DID LAST MARRIAGE END? 13) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
~
OJ
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18T 0 0 18T
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and
as to my right to enter into the marriage state..-;} .
21 SIGNATURE OF GROOM ~' ~ T.... 22, SIGNATURE OF BRIDE ~
US
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNA TURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York S te of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies withl 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 <t318H'altJ. Morse 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
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{ SEAL }
'-v-'
o 0
o 0
o 0
o 0
o legal impediment exists
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
STATE
27, T'fPE OF CEREMONY
o d RELIGIOUS 1 0 CIVIL
ZIP
AM 04
2:53 PM
10
2002 06
08 2002
STREET
I CERTIFY THAT I SOLEMNIZED 26. SOLE
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME
DATE AND AT THE TIME AND II '"J0 AM
PLACE INDICATED PM r;; I
29 OFFICIANT r (Q V'\ V'\ It.. .... Of '\r
NAME (PRINT) '-.::> \-::> S l?C ~........
SIGNATURE ~ 11<1 dO^- ~.t~
MAILING ADDRESS '4J=i. \
s6Gv-e.....'"'- V0""t... \.vc.,\\'(,\\
STREET CITY;TOWN
30. WITNESS TO CEREMONY
f>;ErEJ<.. N O"5/l_~
NAME (PRINT) .
02
9 0 OTHER, SPECIFY
TITLE
~-C~Il.G"";""
28, PLACE WHERE MARRIAGE OCCURRED ,
A, STATE NEW YORK B, COUNTY pv +"'''.f'-.
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF r1t VILLAGE OF
DATE
G 1/ 101.
rvy
STATE
\,-$~
SPECIFY
col J c,f'/I.' ^J (r-
SIGNATURE ~
DOH-98 111/98)