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COUNTY Dutchess
CITYrrOWN Wappinger
~~J~~C:1368 .
~5~~J~R 52
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
William Joseph Baroch
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Chama Kara Archimede
MIDDLE CURRENT SURNAME
.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
...
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)., 48 56-8113
D. SOCIAL SECURITY NUMBER . I -
2. RESIDENCE A. WA B. Whatcom
(STATE) (COUNTY)
C. CHECK ONE 0 CITY..o TOWN 0 VILLAGE
~~CIFY DeminQ
D. STREET ADDRESS 2996 Clipper Rd ZIP 98244
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YESY"D NO
3. A. AGE 50 3B. DATE OF BiRTH 06 /18 /1959
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE~ 09-58-741 8
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA'!VA BWhatcom
(STATE).L. (COUNTY)
C. CHECK ONE 0 CITY 'U TOWN 0 VILLAGE
AND D .
SPECIFY emmg
D. STREET ADDRESf996 Gllpper Kd
4. EMPLOYMENT
A. USUAL OCCUPATION Truck Driver
B. TYPE OF INDUSTRY OR BUSINESS ARC Of Washington
5. PLACE OF BIRTH Dumont, New Jersey
(CITY. STATE I COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATIONHouse Cleaner
B. TYPE OF INDUSTRY OR BUSINESSSe1f Employed
15. PLACE OF BIRTHPoughkeepsie, New York
(CITY, STATE I COUNTRY IF NOT USA)
zlpt:le~44
01..
o YES 0 NO
)970
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AG~9 3B. DATE OF BIRTH 06 ,-to
MONTH DAY
6. FATHER
A. NAME John H. Baroch
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Gladys M. Kelly
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o '0
16. FATHER
A. NAMEJohn Archimede
'B. COUNTRY OF BIRT~taly
17. MOTHER
A. MAIDEN NAME Claudia Aguiar
B. COUNTRY OF B;JJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVfOUS MARRIAGES WHICH ENDED BY
DOORCE CIVIL A'ONULMENT
DEATH
o
DlO.TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
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
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 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
as to my right to enter into the ma ge state.
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF BRIDE~
o 0
o 0
o 0
o 0
at I declare that no legal impediment exists
- ~(~~
USE CURRENT NAME
U C
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
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
{ } NAME (PRINT) John C. Mas rson
TIME MONTH YEAR
SEAL SIGNATURE ~. DATE 05/18/2010
"- -.J MAll.IttG~I[)flEi$eS AM 05 19 201 0
-v- LU MICCII sh Rd, Wappingers Falls, NY 12590 01 :48 PM
STREET CITYrrowN STATE ZIP
~~~R~:RT~t~ 10~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME DAY YEAR 0 0 RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND _ ./ .01
PLACE INDICATED. 9 Il?" OTHER, SPECIFY O/v-
DATE
05/18/2010
by New York Domestic
MONTH
YEAR
07
17 2010
28. PLACE WHERE MARRIAGE OCCURRED
STATE NEW YORK B. COUNTY OGfRt+ESS
TITLE If I::=l/E trc-N 0
DATE ..:5-- ~3 - ;;;1..0/0
L ~...3
ZIP
31. WITNESS TO CEREMONY
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY PeuGH f( E E f5/ t::--
NAME (PRINT)
SIGNATURE~
C- 'PtF ~(l..
wA/)~
