042
~c.
......N
~~
<
....
ft rJ)
00
r-l
r-l
tll
r....
....00 ~
~!-l >-
"'0)
wbO c(
~I:: C
:5"8. ~ u:::
~p.:5u..
'" tll ~ c(
~:3; ~
~ ~ g
tiiQJ~
a:> u
W.,-l
~!-l
,oCl
~
>-0
<51::
!!;o
....
CI:
~1J"'l
W
CI:
W a:
~OO:Jj
",r-l ::;
~~ ~
CI:O)o
8:3; ~
< ....
>- 0 tl1
I:!:............ ~
~CJ(f)
c.
(/)
STATE OFNEW;YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thomas Michael
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B. Dutchess
(STATEI (COUNTY)
o CITY 0 TOWN IX VILLAGE
Wappingers Falls
D. STREET ADDRESS 6 So. Gilmore Blvd.
C.COUNTY
...
<XIX!TOWN
DISTRICT
NUMBER
REGISTER
NUMBER
Dutchess
Wappinger
1368
42
Kubsch
FIRST
MIDDLE
CURRENT SURNAME
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutrhess
(STATE) (COUNTY)
o CITY ~ TOWN 0 VILLAGE
Wappinger
D. STREET ADDRESS 5 Onondaga Drive
11. A. FULL NAME
C. CHECK ONE
AND
SPECIFY
.,
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
1. A. FULL NAME
8. BIRTH NAME. IF DIFFERENT
C. CHECK ONE
AND
SPECIFY
130-66-1316
MONTH
ZIP 12590
Q[ YES 0 NO
23 /1970
YEAR
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 29 3B. DATE OF BIRTH OC t . /
DAY
A. USUAL OCCUPATION Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Clyde's Auto
5. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE/COUNTRY IF NOT USA)
William Kubsch
England
Sheila Bianco
USA
First
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B HOW DID LAST MARRIAGE END? (3) 0 DiVORCE 13) 0 ANNULMENT (2) L; DEATH
C DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
o ARE ANY FORMER SPOUSE(S) ALIVE? 0 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
w
en
z
w
o
::;
~
{ SEAL }
'-v-I
SIGNATUR
MAILING ADDRESS
PO Box 324.
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
4. EMPLOYMENT
6. FATHER
A. NAME
8. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
8. NUMBER OF THIS MARRIAGE
o C RELIGIOUS
9 [1 OTHER, SPECIFY
~ 61,1/OU
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Laurie A.
FIRST MIDDLE
~
z:i:z
~'=Q W
>-;:>- ~
Ij!~~ .-
>-wz .....
g>-,~ ~
~ u..
! L t=
~:l a:
o"'~ W
U,jllla 0
~z'"
o!:lz
z..._
Wells
CURRENT SURNAME
Kubsch
121-58-4324
ZIP
12590
13. A. AGE
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Ki NO
13.B.DATEOFBIRTH July / 6 /1966
MONTH DAY YEAR
33
14. EMPLOYMENT
A. USUAL OCCUPATION
Unemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH (CITY. STAT~C~~N~~~~g: ~SA~ew York
16. FATHER
A. NAME
B. COUNTRY OF BIRTH USA
John Wells
17. MOTHER
A. MAIDEN NAME
8. COUNTRY OF BIRTH
Rose Villanti
USA
First
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
OEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT .21 [1 DEA",
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES '0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATICN
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
SIGNATURd~
L...
TIME
25. 8. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
1ST C :J 1ST
2ND ~ 2ND
3RD D 0 3RD
4TH 0 0 4TH
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare tha1 no legal impediment eXists
as to my right to enter into the m~rriage state. ,
21 SIGNATURE OF GROOM ~ 22..SIGNATURE OF BRIDE ~ ~-l (I III Q ~ t..0 it QjJ. A .
0'\ '- - USE ~T NAME "lioIoo
De ut Town Clerk DATE April 19. 2000
This license authorizes the marriage in New York ate of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
:::J If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
Ela Town Clerk
DATE 4/19/00
Wappingers Falls. NY 12590
CITYrrOWN TATE
27. TYPE OF CEREMONY
MONTH
YEAR
MONTH
DAY
YEAR
ZIP
AM
1 : 30 PM
00
4
20
00
6
18
1J( CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY]) CL ~~~
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 'ti. TOWN OF 0 VILLAGE OF
SPECIFY YO f.,( t5ffl<et5 () S Ie
