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052 + W ~ -.:t -.:t C\I co 0'> !z < ... ~~ ~ ~ C ..J - ;jclllL&. ~'E~ ~ ~c3~ ~ g !!2-o5 ffic::: a: w'- ~Q) If a: ~= ...() o I!!CO ~O'> u:0'> i=C\l a: w U w a: w i Ul Ul w a: c c 0( ~ iii ... Ul a;' W lEI ::i => Z Q ~ $ ~ w -en z -W o -::J + z' . a:i!'t5 ~jfi= a;"'~ ti~~ ;jUW ~~g z- ~~~ ~ocn 0....> ..we! ~~'" OW zg~ 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/)~