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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Louis.1 Monmn
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYTOWN WaDpinger
~~~~~CRT 1368
~E~'~J~R 145
A FULL NAME
FIRST
J
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL, SEE REVERSE) 054-61:> nn71
o SOCIAL SECURITY NUMBER ___D::;:!___
2 RESIDENCE A ~~~) York B J~~~)hp.!,:!,:
C CHECK ONE 0 CITY DvtOWN 0 VILLAGE
AND J-h'd
SPECIFY 1 '.1 e Park
D STREET ADDRESS 540 Violet Avenue ZIP 1 ?~:\R
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 ~O
3 A. AGE 2Q 36. DATE OF BIRTH MON~5 / D~1 / YE1~1
4. EMPLOYMENT
A. USUAL OCCUPATION ConstnJction
6. TYPE OF INDUSTRY OR BUSINESS Sp.1f Fmployp.rf
5 PLACE OF BIRTH POllnhkp.p.n~ip. Np.w York
(CITY. smEicouN'ffiY IF NOT USA)
6. FATHER
A. NAME Louis MOfano G
6. COUNTRY OF BIRTH t J S A
7. MOTHER
A. MAIDEN NAME lynnette Velie
B COUNTRY OF BIRTH II S A
B NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A. NLlMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
(2) 0 DEATH
B. HOW 010 LAST MARRIAGE END? (31 0 DIVORCE
(3) 0 ANNULMENT
/ /
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. STATEiCOUNTRY. IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
f)J)4rt
It7.3/~t7{
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
lhwl J Dunham
~1~l1L'EI' tv\l~ENT SURNAME
~
11. A. FULL NAME
FIRST
B BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C s~~~~~JN~~E~~t~~e~~SE) Morano
o SOCIAL SECURITY NUMBER 124-72 4231
12 RESIDENCE A "Mr}llf;)York B Q~ess
C CHECK ONE 0 CITY 0 ~WN 0 VILLAGE
AND
SPECIFY La Grange
D. STREET ADDRESS 152 Smith Road ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? eYES 0 wI'lO
13. A AGE 22 13.8. DATE OF BIRTH MOJW / ~~ /~la
14. EMPLOYMENT
A. USUAL OCCUPATION Waitre')O~
6. TYPE OF INDUSTRY OR BUSINESS Charlie Brown's Steak
15. PLACE OF BIRTH (cRJwt~&,.m;:';~Il~jnn8sota
16. FATHER
A. NAME Terry Dunham
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Kayle Brandt
B COUNTRY OF BIRTH US!'.
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) D DEATH
B HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES D 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
0 c
c c
0
1ST
2ND
3RD
4TH
I. being duly sworn, depose and say, th
as to my right to enter into the marrlag
21 SIGNATURE OF GROOM ~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
knowledge and belief that the information 1 provided I
22. SIGNATURE OF BRIDE
23 SUBSCRIBED AND SWORN TO BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York S
Relations Law ~ 11 to perform marriage ceremonies withi
o If checked, this license is
24. TOWN OR CITY CLERK
DATE 10/25/2001
te of the bride and groom named above by any person authorized by New York Domestic
New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o be used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO.
DATE AND AT THE TIME AND /) va / ()
:~A::~:,I:::ED~f(e:~.3~'~ ~M ~ ~Y>C"""
NAME (PRINT) r /1 I " ~ =-
SIGNATURE ~ . 'A"l/!:'14J2/ DATE Oer. :;r; cJ Or) i
MAILING ADORE / I J
/ i RG~ V'" I~ Ii. (,.{/1/{JP/1'f(]...G/2S h9.LL(' AIl/. /.?57'~
STREET CITY/TOWN / STATE
30. WITNESS TO CEREMONY
,,-
~
{ SEAL }
'-..t-i
NAME (PRINT)
25 B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON
TIME
MONTH
YEAR
MONTH
DAY
YEAR
10'25'200
10
26
20 1 12
ZIP
24 200t
2B. PLACE WHERE MARRIAGE OCCURRED
9 0 OTHER, SPECIFY
RELIGIOUS
1~ CIVIL
A. STATE NEW YORK B. COUNTY'})ure..Hgs
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF)!f. TOWN OF C VILLAGE OF
SPECIFY LA- Otc.t9-AJG-E..
TITL~~mbc J:vtJ ;;;;rc~ #.:29 /
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/9B)
31.
NAME (PRINT)
SIGNATURE ~