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Dutchess
Wappinger
1368
1 U1
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
W.
MIDDLE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
/~'}~loTl
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Mic.helle A.
FIRST MIDDLE
~
~han 1 P'ls
CURREN SURNAME
1. A. FULL NAME
Robert
FIRST
~idote
CURRENT SURNAME
, ,. A. FULL NAME
BIRTH NAME. IF DIFFERENT
B. BIRTH NAME ;MAIDEN NAME), IF DIFFERENT Korn
c. SURNAME AFTER MARRIAGE S ido t e
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 106-64-2398
12. RESIDENCE A I~n~ Ynrk B. ~!?'u~~re1'l1'l
C. CHECK ONE 0 CIIY 0 TOWN BJ VILLAGE
AND
SPECIFY W::lppingpr!'l F::lll!'l
D. STREET ADDRESS "iR M::lrkpf"' Sf" ZIP 1? "iQO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE' JC YES = NO
13. A. AGE 1"i 13.B.DATEOFBIRTH Anril/ 07 /lQ[;"i
M\5NTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 073-58-4053'
o SOCIAL SECURITY NUMBER --- -- ----
2 RESIDENCE A ~~.wE)Ynrk B. 2~u~~re1'l1'l
C. CHECK ONE 0 CIIY 0 TOWN ill! VILLAGE
AND
SPECIFY W::lppingpr!'l F::ll1!'l
o STREET ADDRESS "iR M::lrkpf" Sf"
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 1 Q 3B. DATE OF BIRTH All a . /
'iOONTH
ZIP 1 ?"iQO
Dc YES 0 NO
? 1 / 1 q[;O
DAY YEAR
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Office/House Cleaner
B. TYPE OF INDUSTRY OR BUSINESS Mid Hudson Of f ice Clear
15. PLACE OF BIRTH Monticello New York
(CITY. STATElCOUNTRY IF NOT USA)
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A. USUAL OCCUPATION Laborer
B. TYPE OF INDUSTRY OR BUSINESS V /Wapl" Hiq:hwav Dept.
5. PLACE OF BIRTH Poughkeepsie New York
(CITY. STA~COUNTRYiF NOT USA)
6. FATHER
A. NAME Frederick Sidote
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Dorothy 0' Riley
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE First
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
16. FATHER
A. NAME Wilmer T. Korn
B. COUNTRY OF BIRTH TTSA
17. MOTHER
A. MAIDEN NAME Maryloll E. Lake
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE
Second
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
One
DEATH
B. HOW DID LAST MARRIAGE END?
(31 0 DiVoRCE
. 31 0 ANNULMENT
/ /
(21 0 DEATH
B. HOW DID LAST MARRIAGE END? ;3) GCDIVORCE (3) = ANNULMENT 2\ _ JEA TH
C.DATElASTMARRIAGEENDED? 1111y /1[; /lqqR
MONT~ DAY vEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE' ~ YES = NO
20. 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
7/16/98 Dutchess Co. NY ~
C. DATE LAST MARRIAGE ENDED'
YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? = YES := 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
15T 0 0 15T
~ := 0 ~
3RD 0 [] 3RD
4TH 0 ::J 4TH -c
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. ()' n "*'- '. '. .
21. SIGNATURE OF GROOM ~ ~ W ~ 22. SIGNATURE OF BRIDE ~ \'"'Y)~\JJ-C.... ~t\c.. ~-\
us CURRENT N USE CURRENT NAME \
Deputy Town Clerk
DATE Au~. 1. 2000
by New York Domestic
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York 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.
::J If checked. this license is to be used onl for the u se of a second or subsequent ceremony.
24. TOWN OR CIIY OLERK 25. A. SOLEMNIZATION PERIOD BEGINS
Elaine H. Snowden, Town Clerk
DATE 8/01100
4, Wappingers Falls, NY 12590
CITYfTOWN STATE
27. IYPE OF CEREMONY
09
30
00
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON'
,-"-.,
{ SEAL}
'-..t-I
NAME (PRINT)
MONTH
DAY
YEAR
TIME
MONTH
DAY
YEAR
SIGNATURE ~
M~~NQl8~RE
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
00
1 : 40 AM
PM
08
02
ZIP
l~IL
A. STATE NEW YORK B. COUNTY o.u~E?~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF ~LLAGE OF
l.0 A.f' f ;.t-J ~ft";) F;.cL.L- ~
SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
RELIGIOUS
OTHER. SPECIFY
3 3C PM
..i. /!J.~LO i,t,U~
TITLE
NAME (PRINT)
SIGNA TURE ~
DOH-ll8 (1198)
(PRINT)
.
SlGNATURE~