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COl~lY
CITYITOWN
DISTRICT
NUMBER
REGISTER
NUMBER
5T A TE OF NEW YORK
DEPARTMENT OF HEALTH
AFADA~~UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Anthony T.
FIRST MIDDLE
I STATE FILE NUllBER I
(THIS SPACE FOR STATE USE ONLY)
./q J?-vJOD
Lo SUPPLEMENTAL FILE .J
Dutchess
Wappinger
1368
166
FROM THE BRIDE
Perpetua N.S.
FIRST MIDDLE
L A. FULL NAME
Straka
CURRENT SURNAME
1 L A. FULL NAME
Dourado
CURRENT SURNAME
De Souza
STRAKA
0.
N
B BIRTH NAME. IF DIFFERENT
B. BIRTH NAME ,MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER
12. RESIDENCEA New York
I STATE)
D CITY Xl TOWN
Wappinger
o STREET ADDRESS 1 9 11 R t e .
ZIP
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
New York
(STATEI
C CITY Xl TOWN D
Wappinger
o STREET ADDRESS 712 Chelsea Cay
n/a
2. RESIDENCE A.
044-44-4368
B. Dutchess
(COUNTY)
VILLAGE
C. CHECK ONE
AND
SPEC:FY
B. Dutchess
(COUNTY)
D VILLAGE
C. CHECK ONE
AND
SPECIFY
376
12590
ZIP 12590
DYES~NO
6 /1950
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 42 13.B. DATE OF BIRTH July /28
MONTH DAY
YES ro NO
/1958
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3 A. AGE 50 3B. DATE OF BIRTH July /
MONTH
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION
Unemployed
w
....
<(
....
'"
A. USUAL OCCUPATION Saf e ty & Health
B. TYPE OF INDUSTRY OR BUSINESS NYCOSH
5. PLACEOFBIRTH Hazleton, Pennsylvania
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME
Manuel De Souza
India
B, TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Goa, India
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Anthony G. Straka
USA
8. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Veronica M. Galovich
USA
Piedade Pereira
India
Second
B. NUMBER OF THIS MARRIAGE
First
lB. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
CIVORCE CIVIL ANNULMENT
DEATH
DEATH
One
B. "CW D'D CAST MARRIAGE END? (3) 0 DIVORCE !31 = ANNULMENT 21 X: DE-A-:~
C. DATE ..AST MARRIAGE ENDED? Dee. / 26 / 1991
MONTH DA Y vEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES ~ NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING iNFORMATICN
DATE OF DECREE PLACE ISSUED AGAINST WHCM
MONTH JAY. YEAR) (CITY, STATE/COUNTRY, IF NOT USAI SELF SPOUSE
B. HOW DID LAST MARRIAGE END? 1.31;::: DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(21 u DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES C 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
1 ST 0 C 1 ST
2ND 0 0 2ND
3RD 0 CJ 3RD
~ 0 0 ~
I. being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal Impediment eXists
as to my right to enter into the marriage state. ~ I"\~
21 SIGNATURE OF GROOM ~ 22. S~NATURE OF BRIDE ~ ~ l:I
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
USE CURRENT NAME
DATE Sept. 11, 2001
Deputy Town Clerk
by New York Domestic
W
en
z
W
u
:i
This license authorizes the marriage in New York St te of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York Slate. THIS LICENSE VALID IN NEW YORK STATE ONLY.
C If checked, this license is to be used onl for the purpose of a second or subsequent ceremony.
~ 24, TOWN OR CITY CLERK 25, A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRI~ Elaine H. Snowden, Town Clerk
{ SEAL SIGNATURE~llLll ~ ~.1 DATE 9/11/00 TIME MONTH DAY YEAR
MAILING ADDRESS 11 : 15 AM
'-v-' PO Box 324, Wappingers Falls. NY 12590 PM 9 12 00
STREET CITYITOWN S ATE ::lP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ./'
~~~SM~=~~~~~V;H5N PT~RE TIME Me DAY Y R ~ ~IL
DATE AND AT THE TIME AND
PLACE IND
11
25. B. SOLEMNIZATION PERIOIl
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
10
00
2B, PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~~
C. LOCATION OF CEREMONY 7 ~
(CHECK ONE AND ~IFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY w4IJIJJ ~
SlGNATURE~ ·
0QH.98 (1198)
SIGNATURE to