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COUNTY
{S~TOWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Samuel R.
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
Dutchess
Wappinger
1368
178
-.J
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Louise M.
Hardy
CURRENT SURNAME
A. FULL NAME
Basso
CURRENT SURNAME
FIRST
MIDDLE
11. A
=ULL NAME
MIDDLE
FIRST
Eagan
BASSO
122-38-9302
B BIRTH NAME. IF DIFFERENT
B. alRTH NAME :MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
OPTIONAL. SEE REVERSE)
SOCIAL SECURITY NUMBER
12 CES:DENCEA. New York 3. Dutchess
'.STATE) ICOUNTYI
v :HECK ONE 0 CITY ~ TOWN :::: VILLAGE
~ND W.
SPECIFY app1nger
J. STREETADDREss1l6 VanVoorhis Terrace ZIP 12590
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE,
o SOCIAL SECURITY NUMBER
2. RESIDENCE A New York B. Du tchess
ISTATEI (COUNTY I
C. CHECK ONE :::: CITY X; TOWN = VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 116 VanVoorhis TerracezlP 12590
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 00 NO
3 A. AGE 55 3B. DATE OF BIRTH Mav / 12 /1945
MONTH DAY YEAR
052-36-1996
_. S RESIDENCE WITHIN LIMITS OF CITY OR INCORPCRA TED VILLAGE?
13. A AGE 52 13.B. DATE OF BIRTH OC to /7
MONTH DAY
YES]t NO
/1947
YEAR
14. E\IPlOYMENT
-!. EMPLOYMENT
A. USUAL OCCUPATION Dispa tcher
B. TYPE OF INDUSTRY OR BUSINESS Bottini Fuel Oil CO.
15. PLACE OF BIRTH Cold Spring, New York
(CITY. STATE/COUNTRY IF NOT USA}
A. USUAL OCCUPATION Vehicle Opera tor
B. TYPE OF INDUSTRY OR BUSINESS Metro North
5. PLACE OF BIRTH Cold Spring, New York
(CITY, STATE COUNTRY IF NOT USA)
16. FATHER
A. NAME Vincent Eagan
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Elsie Graham
B COUNTRY OF BIRTH USA
18. :-<LMBER OF THIS MARRIAGE Second
6. FATHER
A. NAME Vincent Basso
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Domenica Pesacreta
B. COUNTRY OF BIRTH USA
6. NUMBER OF THIS MARRIAGE
First
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE C:Vll ANNULMENT
19. P"EVIOUS MARRIAGES
A. '<UMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNUl\IENT
One
DEATH
DEATH
B HOW DID LAST MARRIAGE "NO'
13::::: DIVORCE
31 0 ANNULMENT
/ /
{21 [J DEATH
8 "OW DID LAST MARRIAGE END? (31lt DIVORCE 31 = ANNULMENT 2' = DEA:H
- :;ATE LAST MARRIAGE ENDED? June / 25 / 1985
MONTH :)A Y
:; ~RE ANY FORMER SPOUSEIS) ALIVE? ~ YES = NO
20 F ""EVIOUSl Y DIVORCED OR ANNUlED. PRCvlCE -HE FOllOWING INFORMATION
JATE OF DECREE PLACE ISSUEJ AGAINST WHOM
\10NTH. DAY. YEAR) ICITY. STATEiCOUNTRYF NOT USAI SELF SPOUSE
6/25/85 White Plains. NY ~
C. DATE LAST MARRIAGE ENDED?
YEAR
V::AR
I.lCNTH DAY
D. ARE ANY FORMER SPOUSE:SI ALIVE? = YES ::J NO
'0. IF PREVIOUSLY DIVORCED OR ANNUL:,D. PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE iSSUED AGAINST WHOM
(MONTH. DAY. YEAR) 'CITY. STATE COUNTRY. IF NOT USA) SELF SPOUSE
1ST :::: 1ST
2ND _ 2ND
3RD-' c: 3RD
~ u ~ ~
i. being duly sworn, depose and say, that to the best of my knowledge and belief that thB r:ormation I provided is true an
as to my right to enter into the marria state.
21. SIGNATURE OF GROOM ~
22. SIGNATURE OF 8RIDE ~
22, 200C
Domestic
W
en
z
W
o
::i
23. SUBSCRIBED AND SWORN TO BEFORE ME
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 911 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
- If checked, this license is to be.used only for the purpose of a second or subsequent ceremony.
~ 24 TOWN OR CITY CLERK k 25. A. SOLEMNIZATION PERIOD BEGINS
NAME IPRINT)~ine H. Snowden, Town Cler
{SEAL} SIGNATURE~-r-chttl~U~,t.n ~tl DATE 9/22/00 TIME MONTH DAY YEAR
MAlllNG.}.DDRE$,S . . 11 . 45 AM
\....- .-J pu .!:Sox j24, Wapp1ngers Falls, NY 12590 . 9 23 00
--y-- STREET -- CITY TOWN STATE PM
~S~R~~~Ri~~J IO~O~~~N~ZEE~ 26 SOLEMNIZATION OCCURRED 27 TYPE OF CEREMCNY
SONS NAMED ABOVE ON THE TIME MO. DAY YEA
DATE AND AT THE TIME AND AM ,.
PLACE INDICATED. IV
11
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON,
MONTH
DAY
YEAR
21
00
28. PLACE WHERE MARRIAGE OCCURR, I '. __
A. STATE NEW YORK 8. COUNTY ~
C. lOCATION OF CEREMONY
(CHECK ONE A' SPECIFY)
[J CITY OF 't/ TOWN OF
VilLAGE OF
SPECIFY
ZIP
31. WITNESS TO CEREMONY
NAME ,PRINT)
S:GMTURE ~