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COUNTY Dutchess
CITYiTOWN Wappinger
1368
13
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Doualas S Rirnstill
MIDDL'E' CURRENT SURNAME
FIRST
:)IAIt. t"ILt. NUMtst:.H
(THIS SPACE FOR STATE USE ONL Y)
;JfJzt
if ' ,j , /~
DISTRICT
NUMBER
REGISTER
NUMBE R
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Fmill/ Nott
MIDDLE 1 CURRENT SURNAME
~
A FULL NAME
11 A FULL NAME
FIRST
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 051- t::>?_ o~O
D SOCIAL SECURITY NUMBER ___ !::L QL!n_
2 RESIDENCE A N Y B. Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY OIllrOWN 0 VILLAGE
AND W
SPECIFY appinger
D STREET ADDRESS 20 Pippin Lane ZIP 12590
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT Picciolo
C SURNAME AFTER MARRIAGE Rirl1!=:till
(OPTIONAL. SEE REVERSE)
D SDCIAL SECURITY NUMBER 077 -61)-117 4
12 RESIDENCE A. N Y B nlltr.hp!=:!=:
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 ""'OWN 0 VILLAGE
AND
SPECIFY Wappinger
D. STREET ADDRESS 20 Pippin Lane
E IS RESIDENCE WITHiN liMITS OF CITY OR INCORPORATED VILLAGE?
o YES O""NO
ZIP 12590
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 ~O
MONV / D97 / 1~~7
38. DATE OF BIRTH
13.B. DATE OF BIRTH
34
3 A. AGE ~3
4. EMPLOYMENT
A. USUAL OCCUPATiON Ceramic Tile Installation
8. TYPE OF INDUSTRY OR BUSINESS Red Hook Tile & Marble
5. PLACE OF BIRTH Pouahkeeosie New York
(CITY, s1'iI:TEiCOUNrny IF NOT USA)
6. FATHER
13. A. AGE
14. EMPLOYMENT
A. USUAL OCCUPATION RI Isin~s Owner
B. TYPE OF INDUSTRY OR BUSINESS Curves For Women
15. PLACE OF BIRTH Rron)( New York
(CITY, STAT~iCOUNTRY IF NOT USA)
16. FATHER
A. NAME Albert Rirnstill
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Marie Da\lenport
B. COUNTRY OF BIRTH l J S A
8 NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A. NUMBER OF PREViOUS MARRIAGES WHICH ENDED BY
DiVORCE CIVIL ANNULMENT
o 0
A. NAME Anthony Pir.dnln
8. COUNTRY OF BIRTH II R A
17, MOTHER
A. MAIDEN NAME Jane Mason
B. COUNTRY OF BIRTH II S A
18. NUMBER OF THIS MARRIAGE ~
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRiAGES WHICH ENDED BY
DiVORCE CIVIL ANNULMENT
? (}
8. HOW DID LAST MARRIAGE END? (3) 0 ~VORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 07/ ?1 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 ~S 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
DEATH
DEATH
(}
(}
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(2) 0 DEATH
1QQR
YEAR
C. DATE LAST MARRIAGE ENDED?
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I, being duly sworn, depos
as to my right to enter into t
o 0 1ST 05/10/1993 POlIghkeepsie, New York 0 0""
o 0 2ND 07/?1/1~~A Pnllohkp.pp!=:ie. Npw Ynrl< 0"" 0
o 0 3RD 0 0
o 0 4TH 0 D
f my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
~: /~ '7? --4.L
utE lUARENT NA~ <--
21
DATE 0?/11/?OO?
by New York Domestic
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23 SUBSCRIBED AND SWORN TO BEFORE M
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 ~11 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
r-^-.
{ SEAL }
'-y-I
NAME (PRINT)
MONTH
YEAR
MONTH
YEAR
TIME
08:4(}M
PM
02
12
20 2 04
12 2002
ZIP
1~
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY~~
CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY au.. b It- fCV{ liS fCL..
ZIP
WITNESS TO C')REMONY ~
NAME (PRINT) .if'/~_ ~dlS-li II
SIGNATURE~ ~