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COUNlt
etffiTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
Dutchess
Wappinger
1368
171)
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
~
L [J SUPPLEMENTAL FILE
FROM THE BRIDE
Melanie Ann
FIRST MIDDLE
Prisco
CURRENT ScRNAME
1. ~ FULL NAME
Kevin
FIRST
John
MIDDLE
Gen!';ch
CURRENT SURNAME
11. ~. FULL NAME
9 BIRTH NAME. :F DIFFERENT
B. BIRTH NAME (MAIDEN NAMEI, IF DIFFERENT
C, SURNAME AFTER MARRIAGE Gens ch
(OPTIONAL. SEE REVERSE)
SOCIAL SECURITY NUMBER 113- 60- 7 339
12 RESIDENCE A, New York B, Dutchess
,5T A TEl COUNTY)
[j CITY x:: TOWN = VILLAGE
Wappinger
607 Chelsea Cay
SURNAME .~r"R MARRIAGE
!OPTIONAL . SEE REVERSE)
SOCIAL SEC~RITY NUMBER
2, RESIDENCE A New York
,STATE:
v' CHECK ONE = CITY ~ TOWN
~ND
SPECIFY LaGrange
D STREETACCRESS t'6~g~~~~~~ ~~r .
E. !S RESIDENCE WITHiN LlMITS'OF CITY OFf'INCORPORATED VILLAGE'
3, A, AGE?7 38. DATE OF BIRTH Sept /27
MONTH DAY
117-66-6180
B, Dll t c he!';!';
,COUNTY)
VILLAGE
C. CHECK ONE
~ND
SPECIFY
ZIP 1? 5 g 0
12603
J STREET ADDRESS
ZIP
_, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE' ~ YES X NO
13. A AGE 26 13,8. DATE OF BIRTH Sent. / 27 /1 g71
MOjqTH DAY yEAR
YES Ql: NO
/1972
YEAR
14, EMPLOYMENT
A. USUAL OCCUPATION
Customer Service Relations
4. EMPLOYMENT
w
>-
'"
>-
<Jl
A, USUAL OCCUPATION Locomotive Engineer
B. TYPE OF iNDUSTRY OR BUSINESS Metro North Railrnad
5, PLACE OF BIRTH Poughkeepsie. New York
,CITY, STArElCOUNTRY IF NOT USA)
6, FATHER
A. NAME John Kevin Gensch
B COUNTRY OF BIRTH USA
7, MOTHER
A, MAIDEN NAME Jeanne Marie Dwyer
8 COUNTRY OF BIRTH USA
B, ~UMBER OF THIS MARRIAGE Firs t
9. PREVIOUS MARRIAGES
,~ NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
:::EATH
DEATH
B, TYPE OF INDUSTRY OR BUSINESS V ~ r i z () -;:-: H -;, r 2 1 -=;;;;
15,PLACEOFBIRTH Beacon. New York
(CITY, STATE-COUNTRY IF NOT USA)
16, FATHER
A, NAME Wayne Joseph Prisco
B, COUNTRY OF BIRTH USA
17, MOTHER
A, MAIDEN NAME T n.<lnn 'T'PT"P C:.<l n.<l,ri c:
B COUNTRY OF BIRTH USA
lB, 'lUMBER OF THIS MARRIAGE Fi r!'; t
19. PREVIOUS MARRIAGES
~, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
a, YOW DID LAS7 MARRIAGE END? 13\= DIVORCE
v' elATE LAST MARRIAGE ENDED?
'.31 = ANNULME~T
/ /
(2):: DEATH
B. HOW DID LAST MARRIAGE END' (3) C DIVORCE
C DATE LAST MARRIAGE ENDED?
,3\ = ANNUL'.IENT
/ /
2 = CEATH
MONTH JAY "~.:.r:
~ ARE ~NY FORMER SPOUSE,S\ ALIVE? = YES = NO
20, F "REVIOUSLY DIVORCED OR ANNUlED, PROVIDE THE FOLLOWING 'r--FCRMATION
JATE OF DECREE PLACE ISSUED AGA.'S-:- WHOM
MONTH, DAY, YEAR) ICITY, STATEiCOUNTRY, IF NOT USA) SE_= 3?CUSE
MONTH DAY YEAR
J ARE ANY cORMER SPOUSE(S) ALIVE? = YES = NO
10, F PREVIOUSLY ellVORCED OR ANNUlED, PROVIDE THE FOllOWING iNFORMATION
DATE OF JECREE PLACE ISSUED -\GAINST WHOM
,MONTH, DAY vEARI ICITY, STATE COUNTRY, IF NOT USA) SELF SPOUSE
1ST
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say. that to the
as to my right to enter into the marriage)1~
21 SIGNATURE OF GROOM ~
w
(J)
Z
W
(,)
::i
2ND
3RD
4TH
est of my kilowlecge and bel' that the information I provided is true and that I declare that no legal ImpeClment eXists
, ~,SIGNATURE OF BRIDE ~ ~ ~- a.. -R/~~
U~E CURRENT NAME
23.SU8SCRIBED-\NDSWORNTOBEFOREME _ Deputy Town Clerk DATESept.20.2000
SIGNATURE CF TOWN OR CITY CLERK ~ r - -
ThiS license authorizes the marriage in ew York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law 911 tD 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 ClE':ine H. Town Clerk 25, A, SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
25. B. SOLEMNIZAT'ON PERIOD
ENOS AT MIDNIGHT ON:
~
{ SEAL}
'-,-I
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
DATE 9/20/00
Wappingers Falls, NY 12590
CITY 'TOWN STATE ZIP
26, SOLEMNIZATION OCCURRED 27, TYPE OF CEREMONY
TIME MO, DAY YEAR 0 ~RELlGIOUS
I ~~ 9 0 OTHER. SPECIFY
AM
2 : 26PM
09
21
00
11
19
00
28 PLACE WHERE MARRIAGE O~'R~~
A STATE NEW YORK B~~
C, lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF .r"jN r i:, VilLAGE OF
SPECIFYr~
1 = CIVIL
TITLE
f( C tfll) t:.I;-
/~h/~,rl
>),01., L/
NAME (PRINT)
SIGNATURE.
SIGNATURE ~