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L D SUPPLEMENTAL FILE
FROM THE BRIDE
Susan Barbara Brugman
FIRST M~e11 CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME)r\ng'ni~~rante
C. SURNAME AFTER MARRIAGE
(OPTIONAL" SEE REVERSEQ) {b-bU-ts~U;:S
D. SOCIAL Sf.3r NUMBER Dutchess
12. RESIDENCE A. B.
(STATE) "'- (COUN1Y)
C. CHECK QtiE, 0 CITY 0 TOWN 0 VILLAGE
AND vvapplnger
SPECIFY 14 19 A t 1 Routt:: :375 12590
D. STREET ADDRESS P ZIP 01
E. IS R~I~NCE WITHIN LIMITS OF CITY OR INCORPORAJf~ VILLAGEh7 0 Y~cQ~O
13. A. AGiP- 3B. DATE OF BIRTH L.. ~
MONTH DAY YEAR
14. EMPLOYMENT D .. I t t
riving ns ruc or
A. USUAL OCCUPATION Driving Instructor
B. TYPE OF IND~inRIMf~I~E~
15. PLACE OF BIRTH ' Y
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER Walter Sell
A. NAME USA
B. COUNTRY OF BIRTH
1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Joseph Eugene Monteferante
FIRST MIDDLE CURRENT SURNAME
I
COUNTY Dutchess
CITYfTO~N wappinger
DISTRICTl 365
NUMBER
REGISTER 14
NUMBER
11. A. FULL NAME
B, BIRTH NAME. IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE122-36-6055
0, SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) JW (COUN1Y)
C. CHECK ON~ ~ CITY TOWN 0 VILLAGE
AND t' hk"
SPECIFY as IS I
D. STREET ADDRESS 314 Koute ~ 1 0 ZIP '12082
01
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES f9 N~
3. A. AGE 62 3B. DATE OF BIRTH 03 /20 / 4
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Department of Transportation
B. TYPE OF IND4,SJRY pR BUSI/'fE.SS Maintenance
5. PLACE OF BIRTH YOnKerS, NY
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Joseph Monteferante
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Dorothy Doyle
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
.J
17. MOTHER MAP b
ary nn a on
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH 2-
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DfORCE CIVIL A'tfULMENT
.,
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVOllfb (3) CO~NULMENT 19~a DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR MONTl,I" DAY' - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY/COUNTY, STATElCOUNTRY.IF NOT USA) SELF SPOUSE 1MQ1fltj1~Y9~)CH(CITYICOUNTY. S....~UNTRYhIF NOT USA) S~ SPOUSE
1ST 0 0 1ST "lUlU' n ,~U Ippewa, IVllcnlga 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swe!lr/affirm, aep'ose and sN, that to the best of. my k.nowledge an7d belief that the information I provided is true and at I declare that no legal impediment exists
as to my nght to enter Into the a,nage state. f.// >' . ;7 ""
21. SIGNATURE OF GROOM ~ /. (- /' -jf2".,- --.,' , 2 SIGNATURE OF BRIDE
, .' USE CUR N I
23. SUBSCRIBED AND SWORN TO/AFFIRMED EFORE ME
SIGNATURE OF TOWN OR.CITY CLERK.
This license authorizes"ihe marriage In New York State of the bride and groom named above by any person authorized by New York Domestic
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 CIT)' C,LERKC M t 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) JOnn . as erson
{YEAR MONTH
SEAL SIGNATURE.
~ MA~tf~df~ 05 14 2010
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVBRCE CIVIL AN~ULMENT
D~TH
"--'
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
D'Ct TH
DATE
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY/)U rrJ!.E<:1f'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF r:. 10WN OF ~ILLAGE OF
SPECIFY t?/./tf/PINGER..r<l., mil.;,
o
ZIP
31. WITNESS T~Y
NAME (PRINT) ~ nE
SIGNATURE~~ 7
SIGNATURE.