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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
John Charles Yanarella. IV
FIRST MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYffOWN Waooinaer
~~~:~: 1368 .
~5~1:~~R63
1 . A. FULL NAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEb 3
D. SOCiAl SECURITY NUMBER 97 -58-607
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITYIIO TOWN 0 VILLAGE
AND W .
SPECIFY apptnger
D. STREET ADDRESS 14 Starrs Crossina ZIP 12590
E. is RESIDENCE WITHIN LIMITS OF CI1Y OR iNCORPORATED VILLAGE? 0 YEs'1J NO
3. A. AGE ~!1 3B. DATE OF BiRTH 05 / 16 ./1975
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Bartender
B. TYPE OF INDUSTRY OR BUSINESS Food Service
5. PLACE OF BIRTH Beacon. NY
(CITY, STATE f COUNTRY IF NOT USA)
6. FATHER
A. NAME John Charles Yanarella III
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Margaret Edith Filkins
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Megan Michelle Epstein
MIDDLE CURRENT SURNAME
--.J
11. A. FULL NAME
FIRST
13. A. AG~3
06
3B. DATE OF BIRTH
MONTH
14. EMPLOYMENT
A. USUALOCCUPATIO~ashion Merchandiser
B. TYPE OF INDUSTRY OR BUSINESsFashion
15. PLACE OF BIRT~oughkeepsie, NY
(CITY. ST ATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEMark Jay Epstein
'B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAMEPatricia Susan Levengood
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
~ YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
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1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is t
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF BRIDE~
23. SUBSCRIBED AND SWORN TO/AF RMED BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~ ATE
This license authorizes the marriage in New authorized by New York Domestic
Relations Law ~11to perform marriage ceremonie 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
{ } NAME (PRINT) Jo . Masters n
TIME MONTH YEAR MONTH
SEAL SIGNATURE. . DATE 06/14/2010
~ MA2~Gl\fi~af~ sh Rd. Wappingers Falls, NY 12590
STREET CITYITOWN STATE ZIP
~~~R~~RT~~~ lo~O~~N~i~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME M. DAY YEAR 0 0 RELIGIOUS ~CtVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
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29. OFFICIANT
NAME (PRINT)
YEAR
02:32 ~~ 06
13 2010
15
2010
08
'+
28. PLACE WHERE MARRIAGE OCCURRED
A, STATE NEW YORK B. COUNTlllyJ-t-4., <s
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o VILLAGE OF
NAME (PRINT)
SIGNATURE~