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CITYfTOwNWappinQer
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~~~~J~~6
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Peter James Scandalis
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
~
1 , A, FUll NAME
11, A FULL NAME
FIRST
lL
f:;j
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
D. s~~:~~~:~u~~~RS'b52-70-8000
2. RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN"TI VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 15 Club House Drive; Unit ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? "'b YES 0 NO
02 /04 /1975
MONTH DAY YEAR
3. A. AGE~!1
3B, DATE OF BIRTH
Y~~2 NO
YEAR
14. EMPLOYMENT
A. USUAL OCCUPATIO~aitress
B. TYPE OF INDUSTRY ORJl.VSI/'lEStood ~ervlce
15. PLACE OF BIRT~hite t-'lalnS, NY
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAM~asil Angelo Garzia
. B. COUNTRY OF BIRT~ S A
17. MOTHER .'
A. MAIDEN NAMElsabel Glsondl
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 2
4. EMPLOYMENT
A. USUAL OCCUPATION Cable Technician
B. TYPE OF INDUSTRY OR BUSINESSCommunications
5. PLACE OF BIRTHMount Kisco. NY
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME James Nicholas Scandalis
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Deborah Louise Mckinstry
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 1
9 PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
. A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~RCE CIVIL ANOULMENT OaTH D1VORCE CIVIL AeNULMENT D{fTH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MAl'IRIAGE END? (3)'6Dlvo1c2 (3) ~ ~NNULMENT205ffl DEATH
C, DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR MON'W' DAY' ',- YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
to
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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY", YEARt . . (CITY/C9UNTY, STAT~OUNTRY, IF NQI USA) SELF SP~SE
1ST 0 0 1ST 12/19/2u08 vvestcnester \jounty, I'IY 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm. depose and say, that to the best of my knowledge and belief that the Information I provided is true and that I declare thal no legal impediment exists
as to my right to enter into the marn estate. ' .
21.SIGNATUREOFGROOM~ . 22.SIGNATUREOFBRIDE~CJ{~ ~
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ;;:E CURR USE CURRENT N~~ 04/09/2QjO
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the 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 onl for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25, A. SOLEMNIZATION PERIOD BEGINS
.n
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
MAILING .AP,D
. '-y-I 20 Mi
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
MONTH
YEAR
MONTH
YEAR
08 2010
2010
06
04
10
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYeJ;l\,("'it ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 6WN OF 0 VILLAGE OF
&0\) A1PP/~ ,.~,
NAME (PRINT)
.,
P
31. WITNESS TO CEREMONY ...L..._
NAME(PRINT)~I ~V,.,
SIGNATURE~ q~