151
~
o
C1'\
lI'\i!!
N<
....
.-.en
~
....~ I-
ffi.-t :>
'" t1l
~~ ~
-'CI)w-
g~~u..
I A' ~ u..
"''''='ct
~ c: ~
~ 0'-; g
~ ~
- t1l u
&1:3
'"
~OO
~ I
~~
+J
~<
'-'
u: .
i= l-l
~~
tl'!.-t
w t1l a:
I.,-;W
~ c: ~
f:3 0 ~
",.-to
g 0 ~
"'U....
,. ~
G~~
w en
a.
.j)
~~~ W
tu~~ I-
~ffiz ct
~d~ (J
:I~g u::
... h ~
\.-.e ~ w
W~~ (J
b~tn
z3~
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Richard P.
FIRST MIDDLE
21 SIGNATURE OF GROOM ~
w
UJ
Z
w
(J
:::;
NAME (PRINT)
SIGNATURE ~
DOH-98 (1198)
; ~\~~"
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Rebecca E.
FIRST MIDDLE
Blumstein
CURRENT SURNAME
~
COUNTY
JllJl!{/TOWN
DISTRICT
NUMBER
REGISTER
NUMB~!1
Dutchess
Wapp;ng~T"
1168
151
11. A. FUll NAME
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Graziano
D. Sri~I~~I~:~;~E;U~~~~RSE) 127 -6 2 - 3913
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
AND
SPECIFY Wappingers Falls
D. STREET ADDRESS 3 Colonial Dr. Apt D-8zIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? x- YES C NO
13. A. AGE 33 13.B. DATE OF BIRTH March /14 ,.1967
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Homemaker
B. TYPE OF INDUSTRY OR BUSINESS Unemployed
15. PLACE OF BIRTH Bronx. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Peter Blumstein
B. COUNTRY OF BIRTH Cuba
17. MOTHER
A. MAIDEN NAME
Ann~ ~;on
'"
1. A. FUll NAME
Graziano
CURRENT SURNAME
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE Fin:;t
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
0-
N
B. BIRTH NAME. IF DIFFERENT
B. HOW DID LAST MARRIAGE END? 1.3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
\21 = JE...\~
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York
(STATE)
C. CHECK ONE ::: CITY 0 TOWN ~ VILLAGE
~~~CIFY Wappingers Falls
o STREET ADDRESS 3 Colonial Dr. AptD8 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? I1f: YES 0 NO
/23 A959
DAY YEAR
061-54-2461
B. Dutchess
(COUNTY)
3. A. AGE
40
3B. DATE OF BIRTH Sept.
MONTH
MONTH DAY 'EAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? = YES C NO
20. IF PREVIOUSLY DIVORCED OR ANNUlED, PROVIDE THE FOLLOWING INFORMATiON
DATE OF DECREE PLACE ISSUED AGAINST WHOM
IMONTH. DAY. YEAR) (CITY. STATE/COUNTRY. IF NOT USA) SELF SPO~SE
l..J 1ST
" 2ND
'-' 3RD
C L 4TH
f my knowledge ~nd belief that the information I provided is l~r that 1 declare,that no leg~ impedime~t e.:(Ists
22. SIGNATURE OF BRIDE ~ ~ ~ /:2i!.J..A./~
USE CURRENT NAME
De ut Town Clerk
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New ork 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 onl for the U sa of a second or subsequent ceremony.
~ ". rowN OR ~' ,. ~ ",-"""noN "'",0"",,",
{SEAL} :::::::~~~ t ~:~:l TIME ~NTH DAY YEAR
MAILING ADDRESS AM
'-t-I B X 1:30 PM 09 01 00
S T
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATE .
4. EMPLOYMENT
A. USUAL OCCUPATION Maintenance
B. TYPE OF INDUSTRY OR BUSINESS Sears
5. PLACEOFBIRTH Brooklyn. New York
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME
Phil
Graziano
USA
B. COUNTRY OF BIRTH
7. MOTHER
Dorothy Idhe
USA
8. NUMBER OF THIS MARRIAGE Firs t
A. MAIDEN NAME
B. COUNTRY OF BIRTH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE !3l 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES C NO
~O. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEARl CITY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
DATE Ang. 11,2000
by New York Domestic
25. B. SOLEMN1ZA TION PERiOD
ENDS" T MIDNIGHT ON:
MONTH
DAY
YEAR
l~IL
10
30
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN
C.
C CITY
VILLAGE OF
STATE
SIGNATURE
