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COUNTY Dutchess
C1TYfTOWN Wappinger
~~J~~c~ 136A .
~~~'~~~R 1 50
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
StevE\t1~ichael R~~&.\NAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Yi
I
FIRST
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FIRST Allison ~~rfle Scicr.~u~lt~ll~NAME
-.J
1. A. FULL NAME
11. A. FULL NAME
Q.
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Robinson
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER OA2-7A-4221
12. RESIDENCE A. NY B. nlltchAS!=:
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY ::Jppmger
D. STREET ADDRESS 34 Kendell Dr ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 1!1 NO
13. A. AGE 29 13B.DATE OF BIRTH n7 /23 /'1981
,:(o\.nH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER 09~-6n-?q 1 n
2. RESIDENCE A. Nx,.ATE) B. Qbt~ess
C. CHECK ONE 0 CITY W!I TOWN 0 VILLAGE
AND \AI .
SPECIFY fvapplnger
D. STREET ADDRESS P () Rox 1175
3. A. AGE 29
3B. DATE OF BiRTH
ZIP 12533
YES ~ NO
/ y1~81
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
MO~~ / D~1
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION W::JitrA!=:!=:
B. TYPE OF INDUSTRY OR BUSINESS Pizza Hut
15. PLACE OF BIRTH Mount Vernon, New York
(CITY. STATE / COUNTRY IF NOT USA)
w
!(
In
A. USUAL OCCUPATION Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Rr::Jrly'!=: POWAr FrJllipmAnt
5. PLACE OF BIRTH (eR.I~.Q~~26~J?R~il~~o~tAf York
6. FATHER
A. NAME Ste\len Phillips
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME Rohin Ann Rohin!=:on
B. COUNTRY OF BIRTH II S A
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
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16. FATHER
A. NAME lohn Sr.i::Jr.r.hit::Jno
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME AnnAtte Capobianco
B. COUNTRY OF BIRTH lJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
n
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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
a:
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say,
as to my right to enter into the marr
21. SIGNATURE OF GROOM ~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
ledge and belief that the information I provided is tru
o
o
o
USE CURRE
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
DATE 10/27/2010
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIONIGHT ON:
~
{ SEAL }
'-.t-I
NAME (PRINT)
DAY
YEAR
YEAR
MONTH
TIME
MONTH
SIGNATURE ~
MAILING ADD S
20 Mi d
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND AM
PLACE INDICATED. , 0 tJ PM , 0
~~~t~~9i~~T _~ f \/. G N At\) 4 D ~ H ~
SIGNATURE~ X
MAILING ADDRESS c~~
\, ~LI~;-DN ~ I . wA-P r )N~t?~5
STREET CITYfTOWN
30. WITNESS T
09:14AM
PM
26 2010
10
28
2010
12
2B. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY 'DoT C" I-t f S ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFY_t\Jl~ vI" i N (rt~r 1='1-\ l..l S
TITLE
DATE
~ALL ~
NAME (PRINT)
SIGNATURE~