058
.;oUNTY
""'~rrOWN
DISTRICT
NUMBER
REGISTER
NUMBER
DlIt"c-hpl'll'l
Wappinger
1368
5'8
51 A 1E OF.iNEW'YORKc
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
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1. A.
FROM THE. GROOM
FULL NAME ~ \~'r.n.rn\ J Def()~
ARS MIDDLE CURRE SllRNAME
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) /~_
o SOCIAL SECURITY NUMBER ".'Sa. q - 5":::L - UI .~
2. RESIDENCE A. A( ei , ' ~ B. --.E.rl Nt ~
lifm, "* (~U~
C CHECK ONE = CITY ~ TOWN 0 VILLAGE
AND In ~
o :::;ADDRE~ \ ~ C?~~~ r. ~ rl 0 ZIP lo~-L
E. IS RESIDENCE WITHiN UMfTS OF CITY OR INCORPOAA TED VilLAGE? 0 YES 0 NO
3. A. AGE 3~ 3B. OATE OF BIRTH Icf.h'" /.:l x: /DJI"
-t MOllTH DAY Y~
4. EMPLOYMENT
A. USUAL OCCUPATION
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH
ICITY. STATElCOU Y IF NOT U )
6. FATHER . T"\
A. NAME~A\(\ J. u.eCr1\1l
B. COUNTRY OF BIRTH l , S fT
7. MOTHER 0 ....\- e \
A. MAIDEN NAME _f.- \ It.l a ~a S 'I" '.
B. COUNTRY OF BIRTH LJ SAn
8. NUMBER OF THIS MARRIAGE ~Q:t:
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
I
.
DEATH
B. HOW DID LAST MARRIAGE END? (3))( DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? ~ /..J "i( / J tlqv
MONTH 'my 'Y8tR
D. ARE ANY FORMER SPCUSE(S) ALIVE? )4 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR1 ,CITY. STATE/ UNTRY. IF NOT USA) SELF SPOUSE
a II
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
/ .;1/(,100
L 0 SUPPLEMENTAL FILE
~
FROM THE BRIDE
11. A. FULL NAME (-)a-l", I ria.. ..J. 'S' nt'll I --\... "
F\mtT MIDDLE CU~ WPlNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE lh, C t'll ~
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER leq -&>Q. -I' 35"
12. RESIDENCE A. ~~ ~ t:'r~ B. (t~.;tne\1Y")
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND V\.... b
SPECIFY , . ,lI;! " ~ ("
D. STREET ADDRESS I <f i2.. ~ 1 f.... (' ( u I P ZIP (0<:'/1
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPOAA TED VilLAGE? 0 YES}{' NO
13. A. AGE 3& 13.B. DATE OF BIRTH (lLI... / fj? /;:;.~
MONT\j 11}" Y YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION ~u~_
B. TYPE OF INDUSTRY OR BUSIN,Et'S _ q,.,1 _ ~~ ~
15. PLACE OF BIRTH a i"r\.a.C'd1~ I~~S
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME ^ \~ ~ L~ f. S' f\ al ucl'(i!~
(J SA
17. MOTHER ~\
A. MAIDEN NAME \.h Gtto-.S p~ e...
B. COUNTRY OF BIRTH ( , 5f\ \ R
18. NUMBER OF THIS MARRIAGE ~rlind!
B. COUNTRY OF BIRTH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
01 \)(J(ce_/
DEATH
B. HOW DID LAST MARRIAGE END?
(3)
C. DATE LAST MARRIAGE ENDED?
MONT!L DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? i'\ YES C NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
( N . DAY, YEAR) (CITY. STATE/COUNTRY. IF NOT U SELF SPOUSE
1ST
2ND
3RD
4TH
I, being duly sworn, depose an
as to my right to enter into the a
o ~ 1ST
o 2ND
o 3RD
o 4TH
nowledge and belief that the information I provided is true and
23. SUBSCRIBED AND SWORN TO BEFOR M
SIGNATURE OF TOWN OR CITY CLERK
This license aulhorizes the marriage in New YDr State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York Slate. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, Ihis license is 10 be used only for the urpose of a second or subsequent ceremony.
24. TOWN OR 25. A. SOLEMNIZATION PERIOD BEGINS
Town Clerk
DATE ~7'7 / on
NY l25~O
A
27. TYPE OF CEREMONY
o 0 RELIGIOUS
21. SIGNATURE OF GROOM
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(,)
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{ } NAME (PRINT)
SEAL SIGNATURE
MAILING ADDRE!i$
'-.t-I P.o. Box J24
s
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
jf 0
o 0
o u
o 0
legal impediment exists
Town Clerk
DATE
by New York Domestic
25. B. SOlEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
AM
i~ ~ 3Z>PM OS-
0~ 00
01
0'7
cd
1 Id"'eIviL
28. PLACE WHERE MARRIAGE OCCURRE~
A. STATE NEW YORK B. COUNTY
NAME (PRINT)
SIGNATURE ..