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COUNTY
~mfTOWN
~J:fJ
REGISTER
NUMBER
Dutchess
Wappinger
1368
171
51 A 1E OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
R
MIDDLE
I
STATE RLE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
/,0/I1/DO
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
-.J
1. A. FULL NAME
David
FIRST
!':i hTPT"n.<li 1
CURRENT SURNAME
11. A. FULL NAME
nit'2
FIRST
M
MIDbLE
KiJJ~Th~
8. BIRTH NAME, IF DIFFERENT
8. BIRni NAME IMAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE S i 1 ve rn ail
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER 051- 5 8- 6 616
12 RESIDENCEA. (~~~ York B l11Juthr~!'l!'l
c. CHECK ONE 0 CITY [1: TOWN 0 VILLAGE
~~~CIFY Beekman
D. STREET ADDRESS 39A Lake Rd.
Ropewe.il J c t .
E. IS RESIDENCE WlnilN L1MrrS OF CITY OR INCORPORATED VILLAGE? C
13. A. AGE 30 13.8. DATE OF BIRTH Dec. /10
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION R.egistered Nurse
B. TYPE OF INDUSTRY OR BUSINESf, NY Medical Imaging
15. PLACE OF BIRTH Broo k 1 vn ~ Npw Y or k
(CITY, STATE/COID'lTRY IF NOT USA)
16. FATHER
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 057-54-4684
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York
(STATE)
o CITY at TOWN
Beekman
B. nl1rl'"hp~!'l
(COUNTY)
o VILLAGE
C CHECK ONE
AND
SPECIFY
D. STREET ADDRESS ':\ qAT ,.<I k P R rl L
ttopeweI.l JCI..
E. IS RESIDENCE WlnilN LIMITs"OF CITY OR INCORPORATED VILLAGE?
3, A. AGE 33 3B. DATE OF BIRTH April /
MONTH
ZIP 12533
ZIP 12533
DYES~NO
27 / 196
DAY YEAR
YES ~ NO
/1969
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Landscaper
B, TYPE OF INDUSTRY OR BUSINESS Twin J' s Lawn Care
5. PLACE OF BIRTH Middletown. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Vinl'"pnr i'.<Ill.<1/HnO
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Lois Albertrani
8. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE Fir s t
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A. NAME Irvin~ R. Silvernail
B. COUNTRY OF BIRTH USA
7. MOTHER
Carol A.
USA
8. NUMBER OF THIS MARRIAGE First
VanLeuven
A, MAIDEN NAME
B. COUNTRY OF BIRTH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
8. HOW DID LAST MARRIAGE END? (3) = DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEAni
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) = DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING iNFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE COUNTRY, IF NOT USA) SELF SPOUSE
r
w
en
z
w
o
::i
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH C
ge and belief that the information I provided is truf-l\.d that I declare that no legal impediment exists
22. SI ATURE OF BRIDE ~ ~ }.{~
USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO BEFORE ME t T C 1 k
SIGNATUREOFTOWNORCITYCLERK~ e u y own er DATE Sept. 15.2000
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New Yorl<. Domestic
Relations Law ~11 to perform marriage ceremonies within New Yorl<. 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 CLER.K 25. A. SOLEMNIZATION PERIOD BEGINS
~ne H. Sowden, Town Clerk
DATE 9/15/00 09 16
10:45AM
NY 12590 PM
TAT ZIP
27, TYp)-OF CEREMONY
o iO"'l'lELIGIOUS 1 0 CIVIL
():) 9 0 OTHER, SPECIFY
c...:
21.
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
"-.,-I
NAME (PRINT)
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
11
14
00
00
SIGNATURE ~
MAILING ADDRESS
PO Box 324
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INOICATED.
Falls
CI rr WN
26. SOLEMNIZATION OCCURRED
TIME MO. OAY Y R
28. PLACE WHERE MARRIAGE OCCURRED () / J--
A. STATE NEW YORK B. COUNTY ~
'3
C. LOCATION OF CEREMONY
(CHECK ONE ANr>PECIFY)
o CITY OF ~rN_OFJD/IL7fJfOF
SPECIFY ~. r~
NAME (PRINT)
SIGNATURE ~
DOH-98 (1198)
SIGNATURE ~