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1 . A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.Jn~Arh Anthnny r,invin::lnq,.. .Jr
FIRST MIDDLE CURRENT SUHNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COUNTY Dutchess
CITYITOWN Wappinger
~~~:kC: 1368 .
~G~I~~~R 102
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
11. A. FULL NAME FIRST M~D~r"en Bar~~kENTSURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Cnnn
C. SURNAME AFTER MARRIAGE Giovin::l770
(OPTIONAL - SEE REVERSE) 093 60 1616
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. NY B. Dutchess
(ST A TO,) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VilLAGE
~~~CIFY Beacon
D. STREET ADDRESS 323 H udson Ave ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES ~ NO
/23 /i961
DAY YEAR
0..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 110 60 7108
D. SOCIAL SECURITY NUMBER _ _ _ - __ - _ _ __
2. RESIDENCE A. NY B. 111 Jtr.hA~~
(STATE) (COUNTY)
C. CHECK ONE Jll CITY 0 TOWN 0 VilLAGE
AND
SPECIFY Be::lcon
D. STREET ADDRESS 323 Hudson Ave ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES r1 NO
3. A. AGE 49 3B. DATE OF BiRTH 1? / ~O / 1960
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION InvAntnry M::ln::lgement
B. TYPE OF INDUSTRY OR BUSINESS Ny State Thruway Auth.
5. PLACE OF BIRTH Suffern, New York
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME .Jn~Arh Anthnny r,invin::lnn Sr
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Frances Rose Bartolotti
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
16. FATHER
A. NAME Donald Henry Coon
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Patricia Louise Neal
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
13. A. AGE 48
13B.DATE OF BIRTH
11
MONTH
w
S
lI)
14. EMPLOYMENT
A. USUAL OCCUPATION Deli Clerk
B. TYPE OF INDUSTRY OR BUSINESS Suoermarket
15. PLACE OF BIRTH Poughkeepsie. New York
(CITY. STATE / COUNTRY IF NOT USA)
W
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z
W
o
::::i
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT
1 0 0 1 0
B. HOW DID LAST MARRIAGE END? (3) c:YDIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) crblVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 12/ 19 / 2000 c. DATE LAST MARRIAGE ENDED? 12 / 09 / 2004
MONTH DAY YEAR MONT!!...,o DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? CMES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? LJYES 0 NO
~
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST 12/19/2000 New City. Ny 0 c:Y 1ST 12/09/2001 PouQhkeepsie, Ny ~ 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, depose and S 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 rr age state. ~
21. SIGNATURE OF GROOM ~ -' 22. IGNATURE OF BRIDE ~ ~t,\( Ct...._ ,;"" p ,
E C U USE UR ENT NAME
23. ~::JfT~~~Do~N.fo~~~~ ci~A~r:fR~E~ BEFORE ME . DATE 08/10/2010
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
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 only for the purpose of a second or subsequent ceremony.
,-1'-,24. TOWN OR CITY CL_ERK._ - - ---. 25. A. SOLEMNIZATION I1ERIOD BEGINS
{ } NAME (PRINT) John C. Masters
TIME MONTH YEAR MONTH DAY YEAR
SEAL SIGNATURE ~ DATE 08/10/201
'- --1 MAILW~ ~D1lIRF!l:>ebu AM
-v- ~U MICCII in ers Falls, NY 12590 02:57PM 08
STREET CITY/TOWN STATE ZIP
~~:R~:RT:~~ 6~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. AY YEAR 0 0 RELIGIOUS~IVIL
DATE AND AT THE TIME AND I<t; \
PLACE INDICATED. 9,... OTHER, SPECIFY ~
DEATH
o
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
11
2010
10
09 2010
28. PLACE WHERE MARRIAGE OCCURRED
29. OFFICIANT
NAME (PRINT)
A. STATE NEW YORK B. COUNTY 0 r-,\~Y' Q
\
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF }(TOWN OF 0 VILLAGE OF
SPECIFY uJa t U hO( k
NAME (PRINT)