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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Tu~as Pa\/la~NTSURNAME
COWTY Dutchess
CITYfTOWN Wappinger
~~~:~; 1368 .
~~~I~J~R 133
1 . A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 100-4R-?ARR
2. RESIDENCE A. N~TATE) B. Q!lLtcmess
C. CHECK ONE 0 CITY I2l TOWN 0 VilLAGE
AND W .
SPECIFY ~rpll"'Oer
D. STREET ADDRESS 11 A Fdgehill nr ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
MOQ~ / D1l / yl~53
3. A. AGE 57
4. EMPLOYMENT
A. USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS r.nn Fd
5. PLACE OF BIRTH Rrnm( NAW Ynrk
(CITY, STAT~ / COUNTRY IF NOT USA)
3B. DATE OF BIRTH
6. FATHER
A. NAME Joseph Illde Pa\Jlacka
B. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A. MAIDEN NAME M~ry .IA~n PAr.~im::ln
B. COUNTRY OF BIRTH I J ~ A
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) c(DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? OW?4 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
09/24/2010 Poughkeepsie, New York d
DEATH
o
(2) 0 DEATH
2010
YEAR
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
T::l m UWlEM::l riA Wi~~~2~ SURNAME
~
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE P~\/I~~k~
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 072-46-2344
12. RESIDENCE A. NY B. nlltr.hASS
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 116 Edgehill Dr ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
/O~ /19A7
DAY YEAR
13. A. AGE 43
04
MONTH
13B.DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION nirednr
B. TYPE OF INDUSTRY OR BUSINESS Health Care
15. PLACE OF BIRTH Bristol, Connecticut
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME RAnp.r1id n::lvirl Wielgns
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Cynthia May Taurinski
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
,.
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
that the information I provided Is true
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and S
as to my right to enter into the
21. SIGNATURE OF GROOM ~
SE CURRENT..
23. SUBSCRIBED AND SWORN TO/AFFIRMED 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.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Joh C. Ma terson
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE 09/28/201
MAILING ADDRE~S 09: 12AM
'-..t-' 20 Midale sh Rd. WappinQers Falls. NY 12590 PM 09
STREET CITY/TOWN STATE ZIP
~~~R~~RT~~J lo~O~~~N:;:i~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 W'RELlGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. ~3 ,,20/0 90 OTHER, SPECIFY
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29. OFFICIANT
NAME (PRINT)
TITLE
by New York Domestic
MONTH
YEAR
29
2010
11
27 2010
26. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
:b.M((
A. STATE NEW YORK B. COUNTY
4-~J
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF 0 TOWN OF 0 VILLAGE OF
DATE
IDI()~ /'7(")/1"\
/
~" /z..
STATE
SPECIFY
~'?~ ~~Jl~
I
LID.
STREET C fTO
". ."""'~ ()
"''''''"'1 : \)l rt " ~v leI...-
SIGNATURE~ ~ (kOt ------
DOH.98 (09/2009)
NAME (PRINT)
SIGNATURE~