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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
TrAvt9JD~Eyrlon W;::!c~l~JjrmRNAME
COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~CRT 1368
~~~I~J~R 121
1. A. FULL NAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 350-72-4474
2. RESIDENCE A. MA B. Norfolk
(STATE) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
AND .
SPECIFY DlJIncy
D. STREET ADDRESS 10 Malvesti Way ZIP 02169
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE 27 3B. DATE OF BIRTH 08 / 1 R / 1 QR~
MONTH DAY YEAR
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4. EMPLOYMENT
A. USUAL OCCUPATION InvA~tmAnt R;::!nkAr
B. TYPE OF INDUSTRY OR BUSINESS Financial Services
5. PLACE OF BIRTH Mt Vernon, Illinois
(CITY, STATE 1 COUNTRY IF NOT USA)
6. FATHER
A. NAME Ri~h;::!rrl nAnni~ W;::!hlhrink
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Sally Joan Lydon
8. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 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
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Michelle Lee Romanski
MIDDLE CURRENT SURNAME
~
11. A. FULLNAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE W;::!hlhrink
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 114-72-7545
12. RESIDENCE A. MA B. Norfolk
(STATE) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
AND Q'
SPECIFY ulncy
D. STREET ADDRESS 10 Malvesti Way ZIP 02169
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? i"1 YES 0 NO
13. A. AGE ~O 138. DATE OF BIRTH 06 /06 ~ 980
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Accountant
B. TYPE OF INDUSTRY OR BUSINESS Accounting
15. PLACE OF BIRTH Poughkeepsie. New York
(CITY, STATE 1 COUNTRY IF NOT USA)
16. FATHER
A. NAME Edward Joseph Romanski
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Ann Maria Panzera
B. COUNTRY OF BIRTH USA
1B. 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? (31 0 DIVORCE (31 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
0:
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1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
UH 0 0 UH 0 0
I duly sweilr/affirm, dep.ose 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 rJghtto enter Into the marriage st~ iYh ~A I A .n .
21. SIGNATURE OF GROOM rff.. 22. SIGNATURE OF BRIDE ~ 7-JlJu( OJ. t ~f~ fJ/IA./1 J ~
DATE 09/03/2010
23. SUBSCRIBED AND SWORN TO/AFFIRME 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
n
TITLE R.... ( fl!..lCsr
DATE ~ Ids/to
{frW, t1/~ '
STATE t-
~
} NAME (PRINT)
{ SEAL SIGNATURE~
~ MAIL~B '}e.ftR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
SIGNATURE ~
MAILING ADDRE;>'S ,
/I U"I'
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) h' (
(11
SIGNATURE~ ' .
DOH.98 (09/2009)
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
08:34A.M
PM
09
04
2010
11
02 201 0
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~U:rCIt(;SS"'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY \11/ ItPP;J../ fTf'R'> htJ-L s.
I~o,o
ZIP
31. WITNESS TO CIiElEMONY
"j
NAME (PRINT)
SIGNATURE~