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1 A. FULL NAME
51 A 1E ,OF,::NEWYORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mathew Steven
FIRST MIDDLE
CURRENT SURNAME
Weibrecht
Vegeto
055-70-5823
New York B Dutchess
(STATE) , iCOUNTY)
o CITY <<i TOWN 0 VILLAGE
Poughkeepsie
47 Hankin Loop
I
STATE FILE NUMSER
(THIS SPACE FOR STATE USE ONL Y)
I
COUNTY Dutchess
~ITOWN Wappinger
DISTAicT 1368
NUMBER
~5~I:J~R 98
~\'I-\ \DV
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Nicole
White
-1
Vegeto
CURRENT SURNAME
11. A, FUll NAME
FIRST
MIDDLE
a.
N
B BIRTH NAME, IF DIFFERENT
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
0, SOCIAL SECURITY NUMBER
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER
2, RESIDENCE A New York B Dutchess
(STATE) . (COUNTY)
o CITY IX TOWN 0 VILlAGE
Poughkeepsie
o STREET ADDRESS 47 Hankin Loop
116-72-7676
C. CHECK ONE
AND
SPECIFY
12, RESIDENCE A.
C, CHECK ONE
AND
SPECIFY
D, STREET ADDRESS
ZIP 12601
ZIP 12601
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES IX NO
Nov. / 18 /1980
DAY YEAR
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Xi NO
13, A, AGE 25 13,B, DATE OF BIRTH DC t . / 24 / 1974
MONTH DAY YEAR
3, A, AGE
19
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
14, EMPLOYMENT
A. USUAL OCCUPATION Contracting
B, TYPE OF INDUSTRY OR BUSINESS Sound Fix
5. PLACE OF BIRTH Poughkeepsie, New York
(CITY. STATE/COUNTRY IF NOT USA)
A. USUAL OCCUPATION Retail Manager
B. TYPE OF INDUSTRY OR BUSINESS Pizza Hut
15. PLACE OF BIRTH Poughkeepsie, New York
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
16. FATHER
A. NAME Steven N. Vegeto
B. COUNTRY OF BIRTH USA
7. MOTHER
A. NAME George W. Weibrecht
B. COUNTfIY OF BIRTH USA
17, MOTHER
A. MAIDEN NAME Diana M. Ricciardi
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
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Debra A. Dubois
USA
B. NUMBER OF THIS MARRIAGE
First
9, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END?
(31 C DIVORCE
B. HOW DID LAST MARRIAGE END? (3) Xi DIVORCE (31 ...J ANNULMENT (21 0 DEATH
C. DATE LAST MARRIAGE ENDED? Dec. /30 /1997
MONTH DAY YEAR
D, ARE ANY FORMER SPOUSE(S) ALIVE? Xi YES :: 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
12/30/97 Washington CO. Vt. }t 0
o
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) C DEATH
YEAR
MONTH DAY
D ARE ANY FORMER SPOUSE(S) ALIVE? :: 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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say. that to the best of my knowl
as to my right to enter into )he marri
21. SIGNATURE OF GROOM ~
23
o ., 1ST
[J ~ 2ND
o 3RD
o 4TH
ge and belief that the information I provided is
;:
c
, ts
22, 2000
w
en
z
w
o
::i
This license authorizes the marriage in New York tate 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 only for the urpose of a second or subsequent ceremony,
24. TOWN OR CITY CLERK 25. A, SOLEMNIZATION PERIOD BEGINS
Elaine H Town Clerk
DATE 6/22/00
NY 12590
STAT
27. TYPE OF CEREMONY
21
00
by New York Domestic
~
{ SEAL }
'-v-'
NAME (PRINT)
TIME
MONTH
YEAR
MONTH
YEAR
SIGNATURE.
MAILlN~ ADDRfi.:
PO BOx ;j
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICA TED.
8: 45 AM
PM
23
4, Wappingers Falls,
CITYiTOWN
26. SOLEMNIZATION OCCURRED
TIME MO, DAY YEAR
AM
PM
00
8
6
ZIP
1~
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYA/~<:;)
C, LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF C VILLAGE OF
OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
SPECIFY
NAME (PRINT)
SIGNATURE~
DOH-98 (11198)
SIGNATURE ~