146
CL
;;:j
r-
Z
ill
(fJ
ill
aJ
g
:::J
o
I
(fJ
Z
o
f=
<t
a:
r-
(fJ
i3
ill
a:
ill
CJ
<t
C(
a:
<t
L
u.
o
ill
r-
<t
U
~
r-
a:
ill
U
ill
a:
ill
I
~
(fJ
(fJ
ill
a:
o
o
<t
~
U
ill
1L
(fJ
z z
~ B W
~ ~ ....
r- Z <C
"5 ~ ()
~ ~ u:
~ u- t=
~ 0 a:
~ ~ W
W 0 ()
I- '"
o
z '"
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES cY' NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d'" NO
3. A. AGE 32 3B DATE OF BIRTH 10 / n2 / 196 13 A AGE 39 13.B DATE OF BIRTH 07 / 07 /1 qR?
MONTH DiiY YEAR MONTH DAY YEAR
19. 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 B. HOW DID LAST MARRIAGE END? (3) 0 ~VORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / / C DATE LAST MARRIAGE ENDED? 02/ 10 /
MONTH DAY YEAR MONTH DAY
o ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 'fES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0 1ST 0?/10/?OOO PnlJghkAAp~ie. New York 0'; 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH C D
ledge and belief that the information I proVi~an~ that I declare that no legal impediment exists
22. SIONATURE OF BRIDE ~ ~ ).A ~ ~
~~EN~
DATE 10/26/2001
/.
23 SUBSCRIBED AND SWORN TO BEF M
SIGNATURE OF TOWN OR CITY CL RK ~
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
DATE 10/26/200
in er Falls NY 12590
ITY/T WN STATE ZIP
27. TYPE OF CEREMONY ~
o D RELIGIOUS 1 I!r'CIVIL
9 D OTHER, SPECIFY
COUNTY Dutchess
CITYrTOWN Wappinger
~~~~~c: 13R8
~~~I~J~R 14R
A FULL NAME
0o~~fJory A H~~ENT SURNAME
FIRST
B BIRTH NAME IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 074-70- ('\1 ~('\
o SOCIAL SECURITY NUMBER ___ -- ;:!_!J;:!
2 RESIDENCE A N Y B. nlltche~~
(STATE) (COUNTY)
C CHECK ONE 0 CITY cYTOWN 0 VILLAGE
AND W
SPECIFY appinger
o STREET ADDRESS 287 Old Hopewell Road ZIP 12590
4 EMPLOYMENT
A. USUAL OCCUPATION Oper~ting Fngineer
B TYPE OF INDUSTRY OR BUSINESS I U 0 E 137
5. PLACE OF BIRTH Pouahkeeosie, New York
(CITY. s"i"ATEiCOUNmy IF NOT USA)
6. FATHER
A. NAME Robert M H~rt I I I
B COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Sharon M Rllndell
B. COUNTRY OF BIRTH I J S A
B NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
DEATH
o
o
w
fJ)
z
w
()
:J
~
{ SEAL}
'-y-I
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
o~t
i 1- lit ..t f
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Rohin M Violinn
MIDDLE CURRENT SURNAME
~
11 A. FULL NAME
FIRST
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT I ~ Rom h~ rei
c. SURNAME AFTER MARRIAGE H~ rt
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER OAA-RO-?A70
12 RESIDENCE A. N Y B Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY D""'OWN D VILLAGE
AND W .
SPECIFY appmger
D STREET ADDRESS 287 Old Hopewell Road ZIP 12590
14 EMPLOYMENT
A. USUAL OCCUPATION Deli Clerk
B. TYPE OF INDUSTRY OR BUSINESS B & L Deli
15 PLACE OF BIRTH Plattsburoh, New York
(CITY. STATE/COunTRY IF NOT USA)
16. FATHER
A NAME Lawrence Leo La Bombard
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME .Io~n M~rjp P~'mpr
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
DEATH
o
(2) D DEATH
2000
YEAR
by New York Domestic
TIME
MONTH
08:5f.M
PM
10
2B PLACE WHERE MARRIAGE OCCURRED
A STATE NEW YORK B COUNTY~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
D CITY OF 0 TOWN OF ~ VILLA~F / i.
SPECIFY t{}A'/f/II?IdJA ~
NAME (PRINT)
SIGNATURE ~