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DRIVER LICENSE
C6221954
ELIZABETH PATRICIA MIC
1286 SIERRA CT
SAN JOSE CA 95 132
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Page 1 of 1
Chris Masterson
From: mary seguine [nursemary100283@yahoo.com]
Sent: Tuesday, December 13, 2005 7:27 PM
To: cmasterson@townofwappinger.us
I have a few questions reguarding getting married. What is required to obtain a marriage license, how
long is it valid for and is there a period of time that we must wait before getting married after we obtain
the document. My fiancee and I were also interested in eloping or having a civil ceremony and we were
unsure of whether the town hall performs such things, if they do who would we get in touch with to find
out more information about this, if not I was hoping that you would be able to provide me with
information on places that perform such ceremonies. If you could please email me back at
nmsemaryJ Q0283@yahQQ-,-com I would greatly appreciate it.
Thank you for your time,
M. Seguine
Yahoo! Shopping
Find Great Deals on Holiday Gifts at Yahoo! Shopping
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12/14/2005
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Page 1 of 1
Sandy Kosakowski
From: Sandy Kosakowski [skosakowski@townofwappinger.us]
Sent: Wednesday, December 14, 2005 6:29 PM
To: 'nursemary100283@yahoo.com'
Subject: marriage inquiry information
A couple who intends to be married in NY State must apply in person for a marriage license to any town or city
clerk in the state.
Although the marriage license is issued immediately, the marriage ceremony may NOT take place with 24 hours
from the time that the license was issued. The marriage license is valid for 60 days, beginning the day after it is
issued.
A marriage license cost is $40.00 payable by cash or check only. The fee includes the issuance of a Certificate of
Marriage
No premarital examination or blood test is required in NY State.
Both applicants must be 18 years of age or older.
You MUST bring proof of age and identity.
One Birth Certificate or Baptismal record AND One Driver's License or Passport.
A marriage may not take place in NYS between an ancestor and descendant, a brother & sister, an uncle and
niece or an aunt and nephew.
Information regarding previous marriages must be furnished. Papers for ALL divorces must be brought when
applying for a license.
Information on civil ceremonies:
The following persons can perform civil ceremonies. All located in the Wappingers Falls area.
Judge Raymond Chase, Jr. 845-297-2943
Judge Vincent Francese 845-297-2282
Marriage Officer, Cheryl Hait 845-297 -6070
All of the above do an excellent ceremony. Just call one of them to make the arrangements that you would be
interested in.
I believe they can charge you a fee up to $75.00 to perform your marriage. (I'm not sure of that amount,
however). You would have to discuss their fee with them.
A NYS marriage license may be used within New York State only.
(Ship captains are NOT authorized to perform marriage ceremonies in New York State).
Hope this information answers your questions.
Sandra Kosakowski / Deputy Town Clerk
12/1412005
-
...
I,;) -I ~ -- c.? 5
Application to Town/City C~rk
for Co of Marria e Record
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Search and 0
Certification Fee $10.00
per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
Search and
Certified Copy
O Fee $10.00
per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
A Certification may be used as proof that a marriage occurred.
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
proceedings, or settlement of an estate.
PLEASE PRINT OR TYPE
Name (First)
of
Groom
Groom's Age
or Date of
Birth
Residence ,,(county)
of, ' \ \
Groom ~l..L '\( Y\JJ. C'~.
Date of Marriage
or Period Covered ('"J
by Search ~C' \-
Place Where
License Was
Issued
(Middle)
(State)
Name (First)
of ..--.-- "
Bride . '( eC
Bride's Age
or Date of
Birth
Residence
of
Bride \
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage Was V ~\
Performed \ {.<.
(Middle)
, '- \ v"-e
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,- \
" \C'"lo%
lst---- \ 1-
County)
lQll2
(State)
~\
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"~..k\
\ ~ \O\S~
For what purpose is information required?
~c C.
~ . ~. ---",t
What is your relationship to person whose record is requested?
If self,~ Je~~
In what capacity are you acting?
If attorney: Name and relationship of your client to persons
whose marriage record is required.
Address of Applicant
\'2- t lU. \ 0 '"s-
Please print name and address where record is to be sent.
u~\ ~\-LG..L
, ~M
'~l~ d
~\'f\
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
Chris Masterson
Town Clerk
Town of Wappinger
20 Middlebush Rd
Wappingers Falls, NY 12590
aL/ct
/~,t/~tJ!3
December 12,2005
Dear Mr. Masterson:
I am writing to request an official copy of my marriage certificate. My name is Alecia
Wartowski (formerly Alecia Humphrey) and I was married to David Wartowski on
October 7, 2005. I have enclosed a $10 check for the certificate. Please mail a copy of
the certificate to me at:
Alecia Wartowski
807 Greenleaf St #2
Evanston, IL 60202
If you have any questions, feel free to contact me at 847 769-1214. Thank you for your
help.
Sincerely,
/lJ?____ ~-/ ~ ~,
Alecia Wartowski
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for COe.>' of Marriage Record
Search and D
Certification Fee $10.00
per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
A Certification may be used as proof that a marriage occurred.
Search and
Certified Copy
Fee $10.00
per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
proceedings, or settlement of an estate.
.... .... ",','",''' ...... ......... ...............' ........ .. ........ ...",.... ...,.. ',' . .. ..
:<B~iIIIQQ.I:BUIl;IEIII:ANQllll1tF-11
PLEASE PRINT OR TYPE
Name (First) (Middle)
of
Groom C. I L
Groom's Age
or Date of <Se~p+ G ~ )
Birth
Residen (County)
~room \ t1- tla
Date of M iage
or Period Covered ;Y1/1- ...J /
by Search I
Place Where
License Was
Issued
(Last)
(State)
. ... .......... .. .... ., H' . .... .. ... ... ..... .
.....................-.............".,....."...................-.
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.............. ...... ....................
.... ............
Name
of
Bride
Bride's Age -
or Date of f} f?r? ( L
Birth
Residence
of
Bride
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage Was
Performed
(First)
'-r
_\C
(Middle)
(Last)
3r
(County)
U +-dus-:;
(State)
IJ
---.-..
Forwhat purpose is information required? . What is your relationship to person whose record is requested?
It.> D'D k n Ca'" ~ '> ~a--k ~ If self, state "self" '7<215;
In what capacity are you acting?
If attorney: Name and relationship of your client to persons
whose marriage record is required.
?~33
DOH-301 (3/93)
Please print name and address where record is to be sent.
(PLEASE SEE REVERSE SIDE)
...-
Application to Town/City Clerk
for Co of Marria e Record
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Search and 0
Certification Fee $10.00
per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
Search and
Certified Copy
O Fee $10.00
per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
A Certification may be used as proof that a marriage occurred.
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
proceedings, or settlement of an estate.
PLEASE PRINT OR TYPE
Name (First)
~room Rc \ ~
Groom's Age
or Date of
Birth
Residence (County)
of
Groom
Date of Marriage
or Period Covered
by Search
Place Where
License Was
Issued
(State)
Name (First)
of .,-.-
Bride" /CiJ/ C,
Bride's Age '
or Date of
Birth
Residence
of
Bride
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage Was
Performed
(Middle)
((
(Last)
tC"lO/1I/c'\..
(Middle)
h
(Last)
(("'ne
(County)
(State)
For what purpose is information required?
What is your relationship to person whose record is requested?
If self, state "self."
In what capacity are you acting?
If attorney: Name and relationship of your client to persons
whose marriage record is required.
c_~
~i.'Vd./i/J
(PLEASE SEE I1lEVERSE SIDE)
/1 t,i/1~
;:2 I ~:5
Please print nam and address where record is to be s~
.& /1 q
. f 0'"1)
~
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\\
DOH-301 (3/93)
-
..
TOWN CLERK ---
TOWN Of WAPP\NGER
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS. NEW YORK 12590
08945
FOR
DATE~
$GFJ
DOLLARS
RECEIVED FROM
...
THIS PAYMENT
BALANCE OUE
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Search and
Certification
O Fee $10.00
per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department. includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
A Certification may be used as proof that a marriage occurred.
Application to Town/City Clerk
for Co of Marria e Record
O Fee $10.00
per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
Search and
Certified Copy
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
proceedings, or settlement of an estate.
..... ..,- .."..... .. ...... ........ ,". .. ... ,". .. .. "",' "'" ',' ..... '" .... ,.. ... .... ......... . ....... ...... .......... ..' .. ............
.........",.."................................................................................ ......... ........................................ .................................................................-...
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. . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . .' . . . . . .' . . . . .' .. . . . .' . . . ..' . . . . . . . . . . . . . . . . . . . . . . . . . ' . . . . . . , . . . . . . . . . ' . . . .
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...,.......................
...................'............
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...... ......................
........'. ...............,.
...... .............. .......
....................................................
................. .........
PLEASE PRINT OR TYPE
Name (First)
of /:"
Groom .
Groom's Age
or Date of
Birth
Residence
of
Groom
Date of Marriage
or Period Covered
by Search
Place Where
License Was
Issued
(Middle)
. (Last)
PH
4.
m ICflE 7 r f
(County)
(State)
/ - /5,..
cJ 00 [)
s <; f "^-I.
~.
In what capacity are you acting?
:t--
6
Name (First) (Middle)
of
Bride Ti II IE A -
Bride's Age
or Date of
Birth
Residence (County)
of
Bride
If Bride Previously
Married. State Name
Used at That Time
Place Where
Marriage Was
Performed
(Last)
(State)
What is your relationship to person whose record is requested?
If self, state "self."
SELF
k
If attorney: Name and relationship of your client to persons
whose marriage record is required.
- J./rJY. I~ ,700
Please print name and address where record is to be sent.
J
~ \~~~
,\ \
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
r-:;(. Fee $10.00
bLJ per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
Search and
Certification
A Certification may be used as proof that a marriage occurred.
Application to Town/City Clerk
for Co of Marria e Record
O Fee $10.00
per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
Search and
Certified Copy
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
proceedings, or settlement of an estate.
.':',',i'."::,::':',':::::>':'::":.>.:::':':::::"::::,:,:,::p,.,..,':U'..:,:,:15......':."'<::&'.."'E"....:':'G'....:O.'.....':g"'''..p'.'.....e..':':':e....'.''l1......'e'......:>.p....'Q:',...."'B'...."M"."'.'.>".,'...':'N'....'.'S....,..,:,:::S...'..<e...'.':M'...':'.,\m..,..'.'''''e'.'....1''''1''.''><'''::'::::':'':'>:::'':':::::'''<:>:':'::'::::,::::,::::,.<:::,::::::::::::::::",:::,:,>><:::::::,'",,:::'<:
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......... .... .,....... ... .. .. ... ,". . ...".. ..".. ",' ...,.. .. .." .... .................... ..... ....., ................ "........
... .,.,.,.,.",', "..,:, <<<..::::.:",,:.-:.........:..... '.:....:::<..:.:...:,.:':...:.... :.,:,:: .:::: ..::: :::. .}:' :::',.:.':....':' :.. }:: .:'. ': . '::/::..': : ..: . ..: ':' ':::':. :",:. ....:..:::':':,:::::::::::::::,::::::::::',':':::::::<..:::,::::,:::::<:::::::::::::,:::,:':'::>:>::'::::::::::::::.::"':'::::,<::<..<..:::::'
...................-.....................;.......:<<.:.:-:.;.:.:.:.:.;.;.:.:.;.;.:.;.:-:.:-:.:.:-:-:<.:.:-:.:-:.:.:.;.;.;.:.:.;.:.:.:.:.;.;.:.:.:.:.;.;.:-:.:-:.:.:.:.;.:.:.:.;.;.:-:.:.:.:.;.:.;.;.;.;.:.:.:.:-:-:.:.;.:-:-:.:.:-:.;.:-:.:.:.:.;.:.:.:-:.:.:.:.:.:-:.:.:-:.;.:.:-:.:.;.:.;...:-:..-:.....:.:.:...:.:.:.:.:.:-:.:.:.:-:.:,:.:.:.;.:.:.:.:-:.:.:.:-:-:-:.....:...:.....:..':-:...........-..........
PLEASE PRINT OR TYPE
Name (First) (Middle) (Last)
of
Groom
Groom's Age . I
or Date of <.0 b '{ (f"YJ <
Birth r -C.:J.....)
Residence (County) (State)
of ~ ") 3 -S\,(",~ ()ri:vIlJ1
Groom ~A- .
Date of Marriage
or Period Covered l 1- ~ - L 9 '8C)
by Search
Place Where
License Was
Issued
For what purpose is information required?
In what capacity are you acting?
(First)
(Middle)
(Last)
uck c
Name
of
Bride
Bride's Age
or Date of
Birth
Residence
of
Bride
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage Was
Performed
~1S i~u~~ 4>u~ ~~
-rJ-L
/I),
~7'
What is your relationship to person whose record is requested?
If self, state "self."
~ ", ry
If attorney: Name and relationship of your client to persons
whose marriage record is required.
Address of Applicant _ .. (\ ~
3 '73 Yl/"'O--f'-..S l Oof'-. f')/\..-
H VI ~ f6-(cK. IV V ) 2.,.S 5 (J
DOH-301 (3/93)
il-Iq~;;
Please print name and address where record is to be sent.
(PLEASE SEE REVERSE SIDE)
.. ,.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Search and
Certification
O Fee$10.00
per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department. includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
A Certification may be used as proof that a marriage occurred.
... .~ /,..
Application to Town/City Clerk
for Co of Marria e Record
O Fee$10.00
per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
Search and
Certified Copy
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's be~efits, ourt . L
proceedings, or settlement of an estate. If
(V
.........................................,.,',..,....-.'............"..........................................'.....................,...............................................,........................................:............,..."......................,...:-......
.....................................................p.--U--....S----J\.......S.S......C----.O...--.M--...--.p----.u--...e--..J.--.e----.....p.--.O.--...R----.M--..--...A--...N----O----.....FJ.--...e--M--...--l.m--....p--..S.--.S..............
..............",............. .. ... . .. . .. .. .. . . .... .' ,.. .... "','"
............:.::.).....:........:..2)\
PLEASE PRINT OR TYPE
Name (First)
of
Groom
Groom's Age
or Date of
Birth
Residence
of
Groom
Date of Marriage
or Period Covered
by Search
Place Where
License Was
Issued
(Middle)
(Last)
~
(State)
(County)
e
Name
of
Bride
Bride's Age
or Date of
Birth
Residence
of
Bride
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage Was
Performed
(Middle)
(Last)
(County)
(State)
For what purpose is information required?
In what capacity are you acting?
Signature of APplican/
f<
Address of Applicant
DOH-301 (3/93)
What is your relationship to person whose record is requested?
If self, state "self."
If attorney: Name and relationship of your client to persons
whose marriage record is required.
Date
Please print name and address where record is to be sent.
(PLEASE SEE REVERSE SIDE)
DURABLE GENERAL POWER OF ATTORNEY
NEW YORK STATUTORY FORM
THE POWERS YOU GRANT BELOW CONTINUE TO BE EFFECTIVE
SHOULD YOU BECOME DISABLED OR INCOMPETENT
Caution: This an important document. It gives the person whom you designate
(your "Agent") broad powers to handle your property during your lifetime, which may
include powers to mortgage, sell or otherwise dispose of any real or personal property
without advance notice to you or approval by you. These powers will continue to exist even
after you become disabled or incompetent. These powers are explained more fully in New
York General Obligations law, Article 5, Title 15, Sections 5-1502A through 5-1503, which
expressly permit the use of any other or different form of power of attorney.
This document does not authorize anyone to make medical or other health care
decisions. You may execute a health care proxy to do this.
If there is anything about this form that you do not understand, you should ask a
lawyer to explain it to you.
THIS is intended to constitute a DURABLE GENERAL POWER OF ATTORNEY
pursuant to Article 5, Title 15 of the New York General Obligations Law:
I, Momcilo Cvijanovic
residing at 8883 Sweetbriar Street, Manassas, VA 20110
Susan 1. Serino,
residing at 38 Mansion Drive, Hyde Park, NY 12538
(If 1 person is to be appointed agent, insert the name and address of your agent above)
do hereby appoint:
(If2 or more persons are to be appointed agents by you insert their names and addresses above)
my attomey(s)-in-fact TO ACT
(If more than one agent is designated, choose one of the following two choices by putting
your initials in one of the blank spaces to the left of your choice:)
(jl( c:.) Each agent may SEP ARA TEL Y act.
)I{ L- ()1'( ) All agents must act TOGETHER.
Y' (Ifneither blank space is initialed, the agents will be required to act together).
IN MY NAME, PLACE AND STEAD in any way which I myself could do, if I were personally
present, with respect to the following matters as each of them is defined in Title 15 of Article 5
of the New York General Obligations Law to the extent that I am permitted by law to act through
an agent:
(Directions: Initial in the blank space to the left of your choice anyone or more of the
following lettered subdivisions as to which you WANT to give your agent authority. If the
blank space to the left of any particular lettered subdivision is NOT initialed, NO
AUTHORITY WILL BE GRANTED FOR matters that are included in that subdivision.
Alternatively, the letter corresponding to each power you wish to grant may be written or
typed on the blank line in subdivision "Q", and you may then put your initials in the blank
space to the left of subdivision "Q" in order to grant each of the powers so indicated.)
(
(
(
(
(
)
)
)
)
)
A) real estate transactions;
B) chattel and goods transactions;
C) bond, share and commodity transactions;
D) banking transactions;
E) business operating transactions;
F) insurance transactions
G) estate transactions;
H) claims and litigation;
I) personal relationships and affairs *;
J) benefits from military service;
K) records, reports and statements;
L) retirements benefits transactions;
M) making unlimited gifts to my spouse; gifts to my children and
more remote descc;mdants, and parents, not to exceed in the aggregate
$10,000.00 to each of such persons in any year;
N) tax matters;
0) all other matters
P) full and unqualified authority to my attorney(s) in fact to delegate
any or all of the foregoing powers to any persons whom my
attorney( s) in fact shall select;
Q) power to deal in, buy, sell or transfer Series E, EE and H Bonds;
R) access to safe deposit boxes/vaults/safes;
S) power to obtain/sign tax returns and deal with all Federal, State
and Local Tax Authorities for all years on all claims, litigation,
settlements and other matters, and for the Internal Revenue Service
to obtain/sign and deal with Forms 1040, 709 and 2848 for the years
1998 through 2008;
T) power to deal with all pension, retirement, incentive, IRA!
Keogh/SEP and similar type plans, programs and annuities;
U) power to create and fund Stand-By and other InterVivos Trust(s);
V) power to borrow funds to avoid forced liquidation of principal's assets;
W) power to handle life, medical, long-term care, homeowners, vehicle
and other insurance, including litigation and settling claims and actions;
X) power to deal with Medicare and Medicaid claims, litigation and settlements;
Y) power to enter into buy and sell transactions;
Z) power to forgive and collect debts;
AA) power to endorse, collect, negotiate, deposit and withdraw Social
SecurityN eterans andlor benefit checks andlor negotiable instruments;
) AB) power to make statutory disclaimers and elections;
) AC) each of the above matters identified by the above letters A through AB
*More particularly any and all rights and powers to obtain copies of my marriage
certificate to Stana Cvijanovic formerly known as Budic. Said marriage occurred on November
8, 1980.
(
(
)
)
( )
( AA C-)
( )
( )
( )
( )
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
)
)
)
)
)
)
)
)
)
)
)
)
)
)
(Special provisions and limitations may be included in the statutory short form durable power of attorney
only if they conform to the requirements of section 5~1503 of the New York General Obligations Law.)
This durable Power of Attorney shall not be affected by my subsequent disability or
incompetence.
If every agent named above is unable or unwilling to serve, I appoint * to be my agent for all
purposes hereunder.
To induce any third party to act hereunder, I hereby agree that any third party receiving a
duly executed copy or facsimile of this instrument may act hereunder; and that revocation
or termination hereof shall be ineffective as to such third party unless and until actual
notice or knowledge of such revocation or termination shall have been received by such
third party, and I for myself and for my heirs, executors, legal representatives and assigns,
hereby agree to indemnify and hold harmless any such third party from and against any
and all claims that may arise against such third party by reason of such third party having
relied on the provisions of this instrument.
This Durable General Power of Attorney may be revoked by me at any time.
'J Ie '3fIitHe44 "3fI~, I have hereunto signed my name this 13th day of November,
2005,
(YOU SIGN HERE)
//!Q
r
~
ACKNOWLEDGMENT
STATE OF NEW YORK, COUNTY OF DUTCHESS SS:
On the day of November, in the year 2005, before me, the undersigned, a Notary Public in
and for said State, personally appeared Momcilo Cvijanovic, personally known to me or proved to me on
the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument
and acknowledged to me that he executed the same in his capacity and that by his signature on the
instrument, the individual, or the person upon behalf of which the individual acted, executed the
instrument.
/1;;l
tl~,. '-
NoT^f.~ Y PuaLIC MARK H, SERINO 1
Notary Public, Slate nfNY
Regi~tration No. 01 SE4800641
Oualified In Dutchess Cty. ._~V~
AFFIDAVIT THAT POWER OF ATTORNEY IS IN FULL F()It@J!ion Expires Aug. 31, 20.!2.1
(Sign before a Notary Public)
STATE OF NEW YORK; COUNTY OF DUTCHESS SS:
being duly sworn, deposes and says:
1. The principal within did, in writing, appoint me as the Principal's true and lawful
ATTORNEY(S) IN FACT in the within Power of Attorney.
2. I have no actual knowledge or actual notice of revocation or termination of Power of Attorney
by death or otherwise, or knowledge of any facts indicating the same. I further represent that the
Principal is alive, has not revoked or repudiated the Power of Attorney and the Power of
Attorney still is in full force and effect.
3. I make this affidavit for the purpose of inducing
to accept delivery of the following Instrument(s), as executed by me in my capacity as the
A TTORNEY(S) IN FACT, with fuiI knowledge that this affidavit will be relied upon in
accepting the execution and delivery of the Instrument(s) and in paying good and valuable
consideration therefor:
Sworn to before me on
NOTARY PUBLIC
I
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if-"---
- .-.
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BREIS EOLAIS
ADDITIONAL INFORMATION
""1
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~~Ai5~@A~T/.oMANA
';-'" f'<DRLVlNG LICENCE
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~--~-"- .. -- ---'~~'-._"-"'~-""-'- -'-'-'-~-"--""''------ '''^'''-'~''''-~-'''" '-
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le lionadhde r€lir rogha an cheadunai
To be compte.ted by licensee if desired
fuilghrupaan cheadunai
licensee's.blood.group ...........m...............
TOIUU AN oeONTORAORGAN
ORGAN DONOR CONSENT
de.ont6ir duan/kidrieyrfonor [a"
. . ':ont6ir organ/m lti-organ dO'l.O~
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Col!}' of Marriage Record
Search and D Fee $1 0.00 Search and D Fee $1 0.00
Certification Certified Copy
per copy per copy
A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marriage.
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate.
::::::::::::::::~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::_I,:::I_lg.I~::1111:::111:::1111:::11.:::::::::::::::::::::::::::::::::::::::::::::::::~:::::::::::::::::::::::::::!::!:::!::::::::!::::::::::::::::::::::::::::::::::::::::::!:::::::::::~
PLEASE PRINT OR TYPE
Name (First)
of , \
Groom \ ~
Groom's Age
~~ateof S\d \lo I
Residence (County)
~room ~0t:s-\c~
Date of Marriage
or Period Covered
b Search
Place Where
License Was
Issued
(Middle)
(Last)
(State)
\D \\ S\D~
f" <A.- \\51 \J 'i
For what purpose is information required?
~~~ ~ c'nO--\[\'~ e
In what capacity are you acting?
(First)
(Middle)
(Last)
'hiD
Name
of to. \
Bride /\JQ.t'\X:.
Bride's Age
or Date of
Birth
Residence
of ~.\
Bride ~c....."'eSS
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage Was ~op i f'-Ige es FoJ ~ ~ N U
Performed 1" J 1
3 \~O/7 (
(County)
(State)
l\)
What is your relationship to person whose record is requested?
If self, state "s\If."n
s€ \"
If attorney: Name and relationship of your client to persons
whose marriage record is required.
Sig~ture of Ap~t ~
D ~ ~\O
Address of Applicant ~
'Ie.. f\ \~\~e.. \.:~\'- \~
~~~\ ~e~ ~\\$ I kJl( I LS 90
DOH-301 (3/93)
Date
/0/ ;)4/0-5
Please print name and address where record is to be sent.
(PLEASE SEE REVERSE SIDE)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Co of Marria e Record
Search and
Certification
O Fee $10.00
per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
A Certification may be used as proof that a marriage occurred.
Search and
Certified Copy
O Fee $10.00
per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
proceedings, or settlement of an estate.
... ::.::.::::::::::::.>:}}::>.>:.:>}. :::.::.::::ip:::L..>:e:.:.:.::.:::::.s:.:..::e..::. :C.....::.O::...:<M>:..::p.:.:.::u:.::::::.e.:::::J1..:...e.:.>>p..:.:Q:..:.::.e.....::M:::::..:::::A:.:.:::>.::.O.:.:.::::::':"::'::'::'::'M"'::"::::":':":::::..::.:.:.:....::...::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::>:::':::::::::::",:::::::::::::::.:::::::':.::::::::.,: ....
. .............................. .... .... . ." '.' . . .. ... . .... .. ... ... .rd. "Re. ..:mee..e.......................................................
, ."".,..'::::::::::::::::::::::::~~::~::~~::::.::i:::].:.:::::..:.::L::::.::;.:::.:::<:::::{:.::~:;;::::;:~;::L::,::>:.:,:::::...>:....:.:~tt,;..:.::>...::::;::>:.:::.:::::.:...:...>/L.:;:.]',:}~,):~..:::.:.:...:::::...;-.<J~jr\F~:..:.::::-::.:.}>Hrt~]:))::::::::::::::::::::::;::=:;;;;;:;}:::;:;::>;:::.;::::::-. <.'........ . . ., ..
. ... ..........."...................................................................................... ..
PLEASE PRINT OR TYPE
Name (First)
of
Groom
Groom's Age
or Date of
Birth
Residence
of
Groom
Date of Marriage
or Period Covered
by Search
Place Where
License Was
Issued
(Middle)
(Last)
; r\ A~L-D
A.
N cr,J Z
(q' 2.- ~
(State)
(County)
Du+cJ\e<';S
N
[1S-0
W f\ P P It-J G: f d.. S
(Middle) (Last)
L ~;t\A~Lt.:)
Name (First)
~fride "'b d o( e ~
Bride's Age
~~r~ate of 'j IJ I 'I. l:t- l '1'2 c(
Residence (County)
~fride n hLs: s
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage Was
Performed
t
(State)
'/J
\,.)1\ ffr~ 4f J-. S
For what purpose is information required?
~e. -k,,6.,.1 \. klj f\.... () Ass i.., ~(E' '?(l.bS1o.. JV'"""\
In what capacity are you .acting? .:)
So ~ CH>~~v of A~(\<<?'f
What is your relationship to person whose record is requested?
If self, state "self."
S oJ
If attorney: Name and relationship of your client to persons
whose marriage record is required.
Signature o1Z!JO 1) (~
Address of Applicant (
18 fMc.d4> " l ~ LC\V\ e.
Wft-~( ,,J'Sef<;;: ~A-llS
fJe'V.J io.t...r- l2.-~o
DOH-301 (3/93)
Date
Please print name and address where record is to be sent.
S trfI^ ~
(PLEASE SEE REVERSE SIDE)
"..
I'
DUTCHESS COUNTY CLERK RECORDING PAGE
RECORD & RETURN TO:
RECORDED: 01/20/2004
CORBALLY GARTLAND & RAPPLEYEA
35 MARKET ST
POUGHKEEPSIE NY 12601
AT:
14:38:40
DOCUMENT #: 02 2004 729
RECEIVED FROM:
CORBALLY GARTLAND & RAPPLEYEA
GRANTOR:
GRANTEE:
DIMARCO DOLORES
DIMARCO ROBERT
RECORDED IN: DEED
INSTRUMENT TYPE: PA
TAX
DISTRICT: OTHER
EXAMINED AND CHARGED AS FOLLOWS:
RECORDING CHARGE:
39.00
NUMBER OF PAGES:
4
TRANSFER TAX AMOUNT:
TRANSFER TAX NUMBER:
E & A FORM: N
*** DO NOT DETACH THIS
*** PAGE
*** THIS IS NOT A BILL
TP-584: N
COUNTY CLERK BY: TYP /
RECEIPT NO: R05055
BATCH RECORD: B00346
1111111111111111111111
022004729
~}J;,~
COLETTE M. LAFUENTE
County Clerk
/
/ DURABLE GENERAL POWER OF ATTORNEY
NEW YORK STATUTORY SHORT FORM
THE POWERS YOU GRANT BELOW CONTINUE TO BE EFFECTIVE
SHOULD YOU BECOME DISABLED OR INCOMPETENT
Caution: This is an important document. It gives the person whom you designate (your
"Agent") broad powers to handle your property during your lifetime, which may include
powers to mortgage, sell, or otherwise dispose of any real or personal property without
advance notice to you or approval by you. These powers will continue to exist even after
you become disabled or incompetent. The powers that you give your Agent are
explained more fully in New York General Obligations Law, Article 5, Title 15, Sections 5-
1502A through 5-1503, which expressly permit the use of any other or different form of
power of attorney.
This document does not authorize anyone to make medical or other health care
decisions for you. You may execute a health care proxy to do this.
If there is anything about this form that you do not understand, you should ask your
lawyer to explain it to you.
THIS is intended to constitute a DURABLE GENERAL POWER OF ATTORNEY
pursuant to Article 5, Title 15, of the New York General Obligations Law:
That I, Dolores DiMarco, having an address at 9 Pleasant Lane,
Wappinger Falls, New York 12590, do hereby appoint: Robert DiMarco, having an
address at 18 Smoke Rise Lane, Wappingers Falls, New York 12590,
my ATTORNEY-IN-FACT TO ACT
(If more than one agent is designated, CHOOSE ONE of the following two
choices by putting your initials in ONE of the blank spaces to the left of your
choice:)
Each agent may SEPARATELY act.
All agents must act TOGETHER.
(If neither blank space is initialed, the agents will be required to act TOGETHER)
IN MY NAME, PLACE AND STEAD in any way which I myself could do, if I were
personally present, with respect to the following matters as each of them is defined in
the Title 15 of Article 5 of the New York General Obligations Law to the extent that I am
permitted by law to act through an agent:
,-
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ^ ]
{DIRECTIONS: Initial in the blank space to the left of your choice any
one or more of the following lettered subdivisions as to which you
WANT to give your agent authority. If the blank space to the left of
any particular lettered subdivision is NOT initialed, NO AUTHORITY
WILL BE GRANTED for matters that are included in that subdivision.
Alternately, the letter corresponding to each power you wish to grant
may be written or typed on the blank line in subdivision "(Q)", and
you may then put your initials in the blank space to the left of
subdivision "(Q)" in order to grant each of the powers so indicated.)
(A) real estate transactions;
(B) chattel and goods transactions;
(C) bond, share and commodity transactions;
(D) banking transactions;
(E) business operating transactions;
(F) insurance transactions;
(G) estate transactions;
(H) claims and litigation;
(I) personal relationships and affairs;
(J) benefits from military service;
(K) records, reports and statements;
(L) retirement benefit transactions;
(M) to make absolute gifts of cash or property to anyone (including, but
not limited to, my attorney-in-fact) or any trust in any amount
without regard for my resources;
(N) tax matters;
(0) all other matters;
(P) full and unqualified authority to my attorney(s) in-fact to delegate
any or all of the foregoing powers to any person or persons whom
my attorney(s)-in-fact shall select;
(0) each of the above matters identified by the following letters:
A, B, C, D, E, F, G, H, I, J, K, L, M, N, 0, P
(Special provisions and limitations may be included in the statutory short form
durable power of attorney only if they conform to the requirements of Section 5-
1503 of the New York General Obligations Law.)
This Durable Power of Attorney shall not be affected by my subsequent disability or
incompetence.
If every agent named above is unable or unwilling to serve, I appoint David DiMarco,
residing at 12 Forest Way, Poughkeepsie, New York 12603 to be my agentfor a/l purposes
hereunder.
To induce any third party to act hereunder, I hereby agree that any third party
receiving a duly executed copy or facsimile of this instrument may act hereunder,
and that revocation or termination hereof shall be ineffective as to such third party
unless and until actual notice or knowledge of such revocation or termination shall
have been received by such third party, and I for myself and for my heirs, executors,
legal representatives and assigns, hereby agree to indemnify and hold harmless any
such third party from and against any and all claims that may arise against such
third party by reason of such third party having relied on the provisions of this
instrument.
This Durable General Power of Attorney may be revoked by me at any time.
#--
J [ IN WITNESS WHEREOF, I have executed this power of attorney this :f day of
~ hJ~M lo.eiL I 2003.
(YOU SIGN HERE:) -+
X
Dolores DiMarco
Dolores DiMarco, because of a physical disability, subscribed her signature by
affixing an "x" to this document; she acknowledged to deponent the "x" with intent
that it be deemed her signature.
STATE OF NEW YORK )
)ss.:
COUNTY OF DUTCHESS)
On the ~ day of N~Vf1i"I~" , 2003, before me, the undersigned, a Notary
Public in and for said State, personally appeared Dolores DiMarco, personally known to
me or proved to me on the basis of satisfactory evidence to be the individual whose name
is subscribed to the within instrument and acknowledged to me that she executed the same
in her capacity and that by her signature on the instrument, the individual or the person
upon behalf of which the individual acted, executed the instrument.
Not
JOHN W. BUCKLEY
NGtary Public, State of New York
No. 02BU6029244
Qualified In Dutchess County~-
Commission Expires AUJ.'!UBt 9. 20J,,!.,)
'''\CI~.(lpr; t\ ";0 RE~I U""I.J.N
n L.~..,I \J ! Oi, L.. :-. i \i ~ t. \
A.LLJ\.i'..J E. F~,'\:::~'~..EYEA, ESa.
.,~c :~!i.J\~iv.~-'r .3THEET
POUC:-;;<YiJ>',::.. N.V.12El01
STATE OF NEW YORK
Department of Health No Record Certification - MarriaJ?;e
District No. 1368
THIS IS TO CERTIFY that a search has been made in this office for the marriage
record of
Labinot Stojkaj
and
n/a
which marriage ,is said to have been solemnized on
n/a
(Date Marriage Solemnized)
at Town of Wappinger , State of New York and that such record is not
(Place Marriage Solemnized)
on file in this office. Search has been made for the period from 08 / 01 / 2001
Month Day Year
to 09 /
Month
23 / 2005 .
Day Year
Witness my signature this
)B d(X>S
'~'---
os: llf j{ }
Town of
}Od~
DOH-3654 (4/93)
WAPPINGER
, New York
VS-13
STATE OF NEW YORK
Department of Health
No Record Certification - MarriaJ?;e
District No. 1368
THIS IS TO CERTIFY that a search has been made in this office for the marriage
record of
Labinot Stojkaj
and
n/a
which marriage is said to have been solemnized on
n/a
(Date Marriage Solemnized)
at Village of Wappingers Falls , State of New York and that such record is not
(Place Marriage Solemnized)
on file in this office. Search has been made for the period from 08 / 01 / 2001
Month Day Year
to 09 / 23 / 2005 .
Month Day Year
Wi tness my signature this d. 3 ~t) day of S.e-p TE: m f;J E R % f) 00 '5
~C2!i~~
.. Clerk
@i:!y
Town } of Wappingers Falls
Village
DOH-3654 (4/93)
, New York
VS-13
" '/~/P
A\~\n~4mber7'2oo5
~ / /' '
.v 0 ~ '.(0
~~,l ~( r\ Mr(
Dear Peggy Decker (or whom it may concern), LiJ tJh
I am writing this letter to request a copy of my maniage license. The following is the P, ~O U
iufonnation that you would need to research this: t
Wife's maiden name: Gertrude Luella Gallagher (may be written as G. Luella Gallagher)
Husband's name: Morton Randall Henderson (or Morton R. Henderson)
Date we were married: June 19, 1949
Place of wedding: New Hamburg, New York (the Methodist church)
Weare trying to go on a trip and in the process of getting our identification papers
together, noticed that our wedding license was missing.
I appreciate any help that you can give us with this situation.
Attached you will find a copy of my driver's license.
RECEIVED
~ 2C35
Thank you,
. t,I. 6 (, /,,- I}
J-
MortonR.~~/ ,~~~~
~YOu cannot find the license at the Town of Poughkeepsie site, Peggy Decker
said that she will attempt to locate it at surrounding areas (ex: Wappingers, Beacon, ect.)
TOWN CLERK
1
JVHLL, ~ tJ~
Signature of Notary Pu lic
v'l/,) "Ie r/\.0 ~ .(
Expiration Date
~ V ~ iJlJ /
)
1\\' c \ \ \ r N'\.i ~ < N\JCi\ \\en bO\
I eo. ~e ::l ood ~e --,1 I _, r_ \ ~ \ \ \'\\ 'l:r
' 5 U45 \)'ChUC'Q t\ l ,
~'l ~~, ~~ c..\l A&. \ G
\ - 5 \.\(j - (\'11 - ol+q() R<::lGt\Cl V,e I \l A 1 \.\D \ q
.
- --
lI' t {- :W.;2"'-!i>'J/"""ir'''''~\'''~{\;jtt'4);'':.'}~\ ~IJ: ."iil: ~
ri'i ~ -, 5 ","" ii
CUSTOMER NO
A69-70-8491
Ii~T
5-07
NOT A lIC
~
DOS
08-24-1926
EXI'tRES
08-24-2011
ISSUED ORl
11-12-2004
COURT CODE
llOERn mRTON RANDALL
II DRIVE APT 1 C
. VA !19-6085
ROANOKE COUNTY
..
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section.
Application to Town/City Clerk
for COe>' of Marriage Record
Search and [] Fee $1 Search and D
Certification 0.00 Certified Copy Fee $1 0.00
per copy per copy
A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marriage.
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate.
PLEASE PRINT OR TYPE
Name (First) (Middle)
of
Groom
Groom's Age
or Date of
Birth
Residence
of
Groom
Date of Marriage
or Period Covered
by Search
Place Where
License Was
Issued
(State)
FP
(State)
,x./.y
Name (First) (Middle)
of
Bride
Bride's Age
or Date of
Birth
Residence (County)
of
Bride
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage Was
Performed
(Last)
~b--t!..l \0
For what purpose is information required?
What is your relationship to person whose record is requested?
If self, state "self."
In what capacity are you acting?
If attorney: Name and relationship of your client to persons
whose marriage record is required.
Date
Please print name and address where record is to be sent.
r.v.
W'7'/I"-?J Q;;1'
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
RECEIVED
- 1105
TOWN CLERK
"
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j ~ NEWYORK STATE DEPARTMENT OF HEALTH
\" Vital Records Section
Application to Town/City Clerk
for Cot!}' of Marriage Record
:::!:l::::::::!:i::::::~::~~::~:~:~:::::::!:!::::::~::::::::::::::::!:::::::!:::::::::j:::::::::;:~:;::::::::::::*:~:~::~:::::~::~::::::!:!:::!:j::::::..:::B:~:111111:::I.IIIII~!:!II.I:I:::IB1:!:::i::~::i:!:::!:!:!:!:!:!:!:!:::::!:!~:~:~!~::!:!:::::!~::::::::::::::::::::::::::::!:!:!:::::::::::!:::!:!:::::::::I:!:::::::::::::::::::::~::::::::::::
Search and D Fee $1 0.00 Search and D Fee $1
Certification Certified Copy 0.00
per copy per copy
A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marriage.
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate.
'*
::::::::::::::::~:::::::~::~::::~:::::::~~:~:::::::::::~:~:~::::::::::::::::::::::::::::::::::::::::::::::::::::~:~~:::::::::~:~:~:::::::::~:~:~:~:..I~~I.II!.I::::fi.I:~:~II.:;IIII:::.II~:~:~:~:::::::::::::::::::::::::::::::::::::::::::j::::::::::::~:::::::::::::::::::::::::::::::::::::::::::~:~::~:::::::::::::::::::::~::::::::::::::
PLEASE PRINT OR TYPE
Name (First) (Middle) (Last) Name (First) (Middle) (Last)
of ~ P~1V4 ?rU- of -7A-t!/1 ANII/ lll/hlES
Groom Bride
Groom's Age Bride's Age
or Date of or Date of
Birth Birth
Residence (County) (State) Residence (County) (State)
of of
Groom Bride
Date of Marriage If Bride Previously
or Period Covered Married, State Name
bv Search Used at That Time
Place Where Place Where
Ucense Was Marriage Was
Issued Performed
For what purpose is information required? What is your relationship to person whose record IS requested?
If self, state "self. "
In what capacity are you acting? If attorney: Name and relationship of your client to persons
whose marriage record is required.
Signature of %ant /~ Date
CcAu ~
Address of Applicant Please print name and address where record is to be sent.
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Coey of Marriage Record
::::\:\::\\:\::\::::\:\\~\[[::::~[:\:::[:\:::::[::~:[\::::[::::::::i:i:i:i:::i:i:::::::::::\::::\::::::\\\\\\\\j::\:::::::::::::::::::::::::::::::::::~:::::.li::1I:::IIIII:I:::IIIIII:\\\IIIII.:::181:::::::i::::::\::::i:::::i:::i\:~\\::::::::::::::i:i:i~i:::::::::i:i:i:i:::::i:::i:i::::::::~.::\::.\[\::~\:::\[:::::~~::::::::::::::::::::::~.:~.~::::[:i::
Search and D Fee $1 Search and ~ee$10.00
Certification 0.00 Certified Copy
per copy per copy
A Certification. an abstract from the marriage record issued A Certified Transcript includes all of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marriage.
the contracting parties. their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate.
[\:::::::::::[:::::::::::::::::::::::::::::::::::::i:::::::::::::::::::::::::::::::::~::::::::::::::::::::::::::::::::::\:::::::::::::::::::::::::llIi.:III:::_lImBI::::1111\::111:\:1\111:::811::::::\::::::\:::::::::::::::::::::)::::::::::[::~::::::::::::::::::::::::::[:::~:::::::[:::::::::::::::::::::[:::::::::::::::::::::::::::::\\::::::
PLEASE PRINT OR TYPE
Name (First) (Middle) (Last) Name (?~ () \ (Middle) (Last)
of Pen aid -m VI rllZ ";) ~r of -") (' n \""eV)
Groom L. Bride
, "'-""1\ \lY
Groom's Age 3 8 I I 0 10 Bride's Age \~() \ ~y;
Date of } I J l Date of 3~ ---
or or "':::::>
Birth Birth
Residence (County) (State) Residence (County) (State)
of 'b~ 1ck':xS \-J ~ of .\J~~~ t0~
Groom Bride
Date of Marriage If Bride Previously
or Period Covered , L\3\Cf~ Married, State Name
by Search Used at That Time
Place Where Place Where
License Was ~ \'l~~ Marriage Was
Issued Performed
For what purpose is information required? What is your relationship to person whose record is requested?
AAt0tx If self, state "self.. S-e1-
"---"' -
In what capacity are you acting? If attorney: Name and relationship of your client to persons
whose marriage record is required.
Signature of APPliCf!awR 1~ Date 3/2 770~
Address of Applicant I Please print name/and address where record IS to be sent.
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Gerald G stanoujgf
FIRST MIDDLE CtJRRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappln~r
~~~~~CRT 1388
~fJ~I~J~R 157
1 A FULL NAME
"-
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 267-85-5705
2. RESIDENCE A New York B. Greene
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN iY VILLAGE
AND
SPECIFY Purling
D STREET ADDRESS 535 J08l Austin Road ZIP 12470
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? cY YES 0 NO
3 A AGE 40 38. DATE OF BIRTH MO~ / ~ / .j~3
4. EMPLOYMENT
A USUAL OCCUPATION Fngineer
B. TYPE OF INDUSTRY OR BUSINESS IBM
5 PLACE OF BIRTH ~1~~~T~~~f,J90~~~)
6. FATHER
A NAME t-I~rry M~rtin Rt~nqlJi!:d
8. COUNTRY OF BIRTH U $ A
7 MOTHER
A. MAIDEN NAME Kathleen .AlIce Moorman
8. COUNTRY OF BIRTH II ~ A
8. NUMBER OF THIS MARRIAGE ,
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
DEATH
001
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) ~EATH
C. DATE LAST MARRIAGE ENDED? 04 / .,,:;: / ?M3
MONTH Dtr" ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES ~O
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
OA TE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
o
o
o
o
o
o
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jane M Monell
FIRST MIDDLE CURRENT SURNAME
~
21. SIGNATURE OF GROOM ~
11 A. FULL NAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Rllg~r
c. SURNAME AFTER MARRIAGE ~~nql Ji!:d
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 129-54-6903
12. RESIDENCE A. New York B. Ulster
(STATE) (COUNTY)
C CHECK ONE 0 CITY 0 TOWN [];!'vILLAGE
~~~CIFY Wallkill
D. STREET ADDRESS 11 Ruger Lane ZIP 12589
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? cY YES 0 NO
13. A AGE 41 13.8. DATE OF BIRTH M~ / ~ ""!ii?
14. EMPLOYMENT
A USUAL OCCUPATION Ph~rrn~r.:y Ter.hnici~fl
8. TYPE OF INDUSTRY OR BUSINESS Pla7a I T C P,",arrnacy
15. PLACE OF BIRTH ~~I~~~lr~o~~ York
16. FATHER
A. NAME .John Ch~r1~ RlJg~r
8. COUNTRY OF BIRTH USA
17. MOTHER
A MAIDEN NAME Katherine Marie Valentino
8. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 08 / no / ~
MONTH D'1!{'" ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? Oo'tES 0 NO
20. 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
08109I2OOO UI~r County, New York 0.,; 0
o 0
o 0
o 0
and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK~ DATE 12/0212003
This license authorizes the marriage in New York any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremDnies wi n 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
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NAME (PRINT)
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
TIME
MONTH
YEAR
MONTH
YEAR
12
03
01
31 2004
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTij)i.l~ Ire;;'~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY . Ii J 11 4df) ~ II. -4 0 I'~
VV' v....'(d /~
ZIP
31 WITNESS TO CEREMONY
NAME (PRINT) ~J) (Ai'\ i e. \ U l f!. f"\ X-
SIGNATURE ~ 'Dr^- 1\, Q. t \. 11 \ ~ ~
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DEPARTMENT OF- HeAL I H
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
CITYfTOWN Wappinger
~i~~~fJ 1 AA1I
~5~I~J~R 158
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
1. A. FULL NAME
MIDJLfmes Smi!ttRENT SURNAME
11. A. FULL NAME
~a M. Se:~ENT SURNAME
FIRST
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE o.:u..
(OPTIONAL. SEE REVERSE) ,""",'U I
D. SOCIAL SECURITY NUMBER 073-5G-7-G19
12. RESIDENCEA. ~f(cnk B Qdlchcu
c. X~5CK ONE 0 CITY 0 ,JIlWN 0 VILLAGE
SPECIFY 'J'Jappinger
D. STREET ADDRESS 108 1868 Route 9 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES D~O
MoGI / 18 /1fOO
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 09)" 36~B646
2. RESIDENCEA. ~)YQrk B ~9EB
C. CHECK ONE 0 CITY o;rOWN 0 VILLAGE
~~~CIFY s;:gqt Fir;z.hkill
D STREET ADDRESS 79 Leke Wilton Road ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
DYES D,;NO
3B. DATE OF BIRTH
13. A. AGE 33
14. EMPLOYMENT
13.B. DATE OF BIRTH
3. A. AGE 57
4. EMPLOYMENT
A. USUAL OCCUPATION Driver
B. TYPE OF INDUSTRY OR BUSINESS UPS
5. PLACE OF BIRTH ~AM~l'~J York
6. FATHER
MO
A. USUAL OCCUPATION MediC81 Biller
B. TYPE OF INDUSTRY OR BUSINESS Dutchess Surgical ~.
15. PLACE OF BIRTH No.*~~oNew York
16. FATHER
A. NAME Kenndh Paul James
B. COUNTRY OF BIRTH USA
17. MOTHER
A. NAME Edward Smith
B. COUNTRY OF BIRTH U $ A
7. MOTHER
A. MAIDEN NAME Mary &fleet
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. MAIDEN NAME Mlchctlle louise &;Iby
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIV!L ANNULMENT
DEATH
DEATH
o
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
100
B. HOW DID LAST MARRIAGE END? (3) Q,l!JIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? f'lE/"~ / ~'"
MONTH - DA".... - I
D. ARE ANY FORMER SPOUSE(S) ALIVE? Q,lfES 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
o
B. HOW DID LAST MARRIAGE END?
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 INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUN~RY, IF NOT USA) SELF SPOUSE
0511612001 Poughkeepslo, Nor;; York
o
o
C\; 1 ST 0 0
o 2ND 0 0
o 3RD 0 0
o UH 0 0
ief that the information I provided is true and that I declare that no legal impediment exists
22.SIGNATUREOFBRIDE~ P. .^^",........ ~oO~
~RENTNAME ~
DATE
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23. SUBSCRIBED AND SWORN TO BE E ME
SIGNATURE OF TOWN OR CITY ERK ~
This license authorizes the marriage in New York St e of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies withi 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
or
omestic
by New
~
{ SEAL }
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TIME
MONTH
YEAR
YEAR
TE 12fOJJ2OOJ
..
2Q04
ZIP
ATE
27. TYPE OF CEREMONY
o~ RELIGIOUS
9 0 OTHER, SPECIFY
A.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF
o VILLAGE OF
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
AM
1:;'~3of!J;/l
10 CIVIL
3- oy
TITLE /VlI A/fs.Tp f(
DATE VtCIlt, g 0 7'
NeW 1J12!(
STATE
29. OFFICIANT
NAME (PRINT)
SPECIFY V ILL It 8 0 R. G H E ~ 1:
\,v' It PP /IVG ER
NAME (PRINT)
SIGNATURE ~
NAME (PRINT)
SIGNATURE ~
DOH-96 (11/96)
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COUNTY Dutchess
CITY/TOWN Wappinger
S~J~kW" 1368
~G~~J~R 159
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rgillt Jghn Tytrit&JI~RNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL ~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
iita L OIMURENT SURNAME
1. A. FULL NAME
11. ^- FULL NAME.
FIRST
Q.
N
B.. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE T ymer
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER Q69..14 7733
12. RESIDENCE ^---Jt..fSXTE) B. ~8SE
C. CHECK ONE 0 CITY 0 TOWN 0 ""ILlAGE
~~CIFY Wappingel5 Falls
D. STREET ADDRESS 7 A Hgh Street ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIlLAGE? ~ES 0 NO
13. A AGE 21 13.B. DATE OF BIRTH MOQ-~ / 11 /1~
14. EMPLOYMENT
A USUAL OCCUPATION Secretary
B. TYPE OF INDUSTRY OR BUSINESS Helling Slnltation
15. PLACE OF BIRTH (~~~ti!l~ Yonc
16. FATHER
A. NAME Emesto .4ntonio OIMeri
B. COUNTRY OF BIRTH Italy
17. MOTHER
A. MAIDEN NAME Ceneetta Susan Romasoa
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
0S6 72 2-431
2. RESIDENCE A. .... V 8 . nutl'h.--s
"~T.uE) . ~m.rrrr "--
C. XI;1gCK ONE 0 CITY 0 TOWN o,lLlAGE
SPECIFY \^IappiRge15 F.allli
D. STREET ADDRESS. 7 A High street
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIlLAGE?
ZIP 12590
O~ES 0 NO
38. DATE OF BIRTH
3. A. AGE 21
4. EMPLOYMENT
A. USUAL OCCUPATION Laborer
B. TYPE OF INDUSTRY OR BUSINESS Hemllg Slnltltion
5. PLACE OF BIRTH (~J'ct~~ew Yonc
6. FATHER
A. NAME Robert John Tumerl Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Jamie L "':estral!
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) 0 DEATH
DEATH
o
o
o 0 0
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 ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
no legal impediment exists
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ ./
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOULOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
o
o
o
o
o
o
23. SUBSCRIBED AND SWORN TO 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)
121051.2003
by New York Domestic
~
{ SEAL }
'-v-I
TIME
MONTH
-.
YEAR
MONTH
YEAR
SIGNATURE ~
MAILING ADDRESS
12J05f.200
12
06
2
302
032004
STRE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMEO ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY .lli+dvss
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF r!'! VILLAGE OF
S~ECIFY 1.JOf(Ji(l IPS .ft-I II S
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
John E Merlino
MIDDLE CURRENT SURNAME
COUNTY [)ut~~
CITYfTOWN Wappinger
~tfJ~kCRT 1368
~G~~J~R 1 SO
1. A. FUll NAME
FIRST
a.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) nD~ A~5880
D. SOCIAL SECURITY NUMBER ~
2. RESIDENCE A. NY B. [)utchess
(STATE) ~ (COUNTY)
C. CHECK ONE 0 CITY LJ"PJ OWN 0 VILlAGE
~~gcIFY East Fishkill
D. STREET ADDRESS 27 Pleasant Hili Road
ZIP 12533
DYES r:rf NO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE?
3. A. AGE 51 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION School Administrator
B. TYPE OF INDUSTRY OR BUSINESS Wappinger cntrJ. Schools
5. PLACE OF BIRTH Bronx. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME John Merlino
B. COUNTRY OF BIRTH USA
7. MOTHER
AngeJlf\A I Atn
B. COUNTRY OF BIRTH USA
3
A. MAIDEN NAME
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to e
as to my right to enter into the marriage S
21. SIGNATURE OF GROOM ~
;-"-.,
{ SEAL}
'-v-I
ATE 12112f200
r Falls NY'12590
STATE
27. TYPE OF CEREMONY
YEAR 0 G-l'lELIGIOUS
(J &{ 9 0 OTHER, SPECIFY
SIGNATURE ~
MAILI~A~T
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
ot
M :00 PM
~~,~,~, ;.' ~ 'sIJ.
NAME (PRINT) \. IV .....
SIGNATURE ~ c,:AI\.. . -;;"t-t-
MAILING ADDRES I S4. f'fe~/e tJ.}.
CITYfTOWN ~~
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Marisa B. Walsh - Cramer
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Walsh
c. SURNAME AFTER MARRIAGE Merlino
(OPTIONAL - SEE REVERSE) 090-68-9902
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B Dutchess
(STATE) . (COUNTY)
C. CHECK ONE 0 CITY 0 "'OWN 0 VILLAGE
~~gcIFY East Fishkill
D. STREET ADDRESS 27 Pleasant Hili Road ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES D"NO
03 / 10 /1967
MONTH DAY YEAR
11. A. FUll NAME
13. A. AGE 36
13.B. DATE OF BIRTH
14. EMPLOYMENT
A.USUAL OCCUPATION Assistant Princi2!!
B. TYPE OF INDUSTRY OR BUSINESS Wappinger CntrJ. Schls.
15. PLACE OF BIRTH CorUandt, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Thomas Vincent Walsh
B. COUNTRY OF ~'RTH USA
17. MOTHER
A. MAIDEN NAME Marla Theresa Pignataro
B. COUNTRY OF BIRTH USA
2
DEATH
o
2082EATH
YEAR
TIME
MONTH
YEAR
ZIP
AM
03:2&1
12
10 'CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYb~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
TITLE /:1,,. ('><;; t-
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~P-I\li., ~ RlAnd
MIDDLE CURRENT SURNAME
lnvv't Jv
DATE / I ,;z16~
tJ'I I;;
STATE
COUNTY nlJtch~
CITYfTOWN W~ppinger
2~J~~c~ 1 ~R
~5~~J~R 161
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF. DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 22r:.1 ':IP ~ A22
D. SOCIAL SECURITY NUMBER _o,.I!!_~
2. RESIDENCE A. ~T'tE) B. ~P!!ILq
C. CHECK ONE D CITY QlItOWN D VILlAGE
AND ,&,_.
SPECIFY "VHppln~
o. STREET ADDRESS 1 ~91 Route 378
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 40 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Autnmnlive Tecllnician
B. TYPE OF INDUSTRY OR BUSINESS MMdtNAand!;
5. PLACE OF BIRTH (~~J~9,~~y~!~~r
6. FATHER
ZIP 12590
DYES' D"'NO
A. NAME .JAm~ MAlAnd
B. COUNTRY OF BIRTH lJ S A
7. MOTHER
Louise Coleman
B. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 2
A. MAIDEN NAME
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) D ~VORCE (3) D ANNUUMENT
C. DATE LAST MARRIAGE ENDED? M/ . ~ /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? ' D..ts D 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
06130I2OO3 Poughkeepsie. N Y
DEATH
o
(2) D DEATH
?OO~
YEAR
1ST
2ND
3RD
4TH
I, being duly swam, depose and say, th
as to my right to enter into the m .
21. SIGNATURE OF GROOM
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23. SUBSCRIBED AND SWORN TO BE ORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York S18
Relations Law ~11 to perform marriage ceremonies '<<!lb'
D If checked, this license is
24. TOWN OR CITY CLERK
~
{ SEAL }
'-.-'
STREET CITYfTO
3D. WITNESS TO CEREMONY . ~
NAME (PRINT) . L~do.. D. rrer
SIGNATURE~ ~J eJ), ~
DOH-98 (11/98)
,.
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
11. A. FULL NAME FIRST R~I~~Jnyr-..e MD~!~~URNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Kre~r
C. SURNAME AFTER MARRIAGE R1li1nd
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 087 _~~?5
12. RESIDENCE A. "'S'XTE) B. ~~~~~CT.
C. CHECK ONE D CITY 0 tIIoWN D VILLAGE
AND W .
SPECIFY 8ppnger
D. STREET ADDRESS 1 Harbor Hili Road
ZIP
12590
YES D""'NO
/1~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D
13. A. AGE 41 13.B. DATE OF BIRTH ~3 / 'i-l
14. EMPLOYMENT
A. USUAL OCCUPATION Dog Groomer
B. TYPE OF INDUSTRY OR BUSINESS SeIf-empl~ed
15. PLACE OF BIRTH Fort Bennina_ GAOrgia
(CITY, STATElCOUNTRY'lrNOT USA)
16. FATHER
A. NAME Jam~ John Krebser
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Barbara Ann Wafford
B. COUNTRY OF BIRTH l J S A
18. NUMBER OF THIS MARRIAGE . 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) D 'l!l'VORCE (3) D ANNUUMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 05/ 01 / 2000
MONTH OA Y YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? D ~S D NO
2D. 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
1ST 05J01f201ll\ POllghkeep5ie. N V D D"'"
2ND 0 D
3RD D D
~ D D
lief that the information I provide is true and that I declare that no legal impediment exists
22. SIGNATURE pF BRIDE ~ ~ ~ ,-- \. 1 Ol\{Pc~
~~ I.
DATE 12/23f2003
named above by any person authorized by New York Domestic
VALID IN NEW YORK STATE ONLY.
o cond or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
DEATH
o
TIME
MONTH
YEAR
MONTH
YEAR
1?J23/200
AM
03:1,M
12
24
2
3 02 21 2004
ZIP
28. PLACE WHERE MARRIAGE OCCURR~
A. STATE NEW YORK B. COUNTY.,l)\J-tc}eS5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF >> TOWN OF D VILLAGE OF
S~ECIFY fO~~\e.
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
lb~- M. M~ SURNAME
FIRST
r
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
1. A FULL NAME
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
8Y11.fol L Lawr~ SURNAME
~
FIRST
11. A FUU NAME
"-
N
8. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SY~~~~N~~~~~t~~C~~SE) Mezger
D. SOCIAL SECURITY NUMBER 108-S8w02BG
12. RESIDENCE A ~[(ork B. Q..,css
C. ~~6CK ONE 0 CITY 0 TOWN 0 J'ILLAGE
SPECIFY 'NappingefS Falls
D. STREET ADDRESS 15 Uss Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? CV"ES 0 NO
MOms / 00 /1961
09a..52-4832
2. RESIDENCEA. ~)Yor.1c B. ~8BB
C. ~~6CK ONE 0 CITY D TOWN Q,v/LLAGE
SPECIFY W~ppinge-IS Falls
D. STREET ADDRESS 1'\ U~S Road
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIUAGE?
ZIP 125gQ
[Vr'ES 0 NO
3. A. AGE 38
4. EMPLOYMENT
A. USUAL OCCUPATION Trude Driver
B. TYPE OF INDUSTRY OR BUSINESS Croton O. P. 'JtJ.
5. PLACE OF BIRTH ~1i#JrJ;~!J~~~ York
6. FATHER
38. DATE OF BIRTH
13.8. DATE OF BIRTH
13. A. AGE 42
14. EMPLOYMENT
A. USUAL OCCUPATION Nul'SC
B. TYPE OF INDUSTRY OR BUSINESS I ludson Vetlfey ; lospltal
15. PLACE OF BIRTH eMkskU~NiI\,Il.bYuark
16. FATHER
A. NAME Harry James Mezger
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Kather-ine MaRe Kevieky
8. COUNTRY OF BIRTH U S .~
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. NAME John Uwlrcncc
B. COUNTRY OF BIRTH USA
17. MOTHER
DEATH
A MAIDEN NAME Carol Joy
8. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0
8. HOW 010 LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) Dr,i'lVORCE (3) 0 ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? MONTH 01 / D.o9 / mY
D. ARE ANY FORMER SPOUSE(S) ALIVE? D~S 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNUL ED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES 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
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1ST 0 0 1ST 0110911997 V.thtte PlM'1:j, NtNv '(wk D Do;
2ND 0 0 2ND 0 D
3RD 0 D 3RD 0 0
4TH 0 0 4TH D D
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the Information 1 provided IS true and that I declare tha~no Ie al Impediment eXists
as to my right tD enter into the m~age state. .... c/
21. SIGNATURE OF GROOM ~ 22 SIGNATURE OF BRIDE ~ ~ a ~ ../ L..-'
USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State
Relations Law ~11 to perform marriage ceremonies within
D If checked, this license is to
24. TOWN OR CITY CLERK
DATE
of the bride and groom named above by any person authorized by New York
w York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
e used only' for tHe purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
omestic
~
{ SEAL }
'-v-I
NAME (PRINT)
YEAR
TIME
MONTH
YEAR
TE 121291200J
AM
PM
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
A.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
D CITY OF D TOWN OF ~ VILLAGE OF
SPECIFY
NAME (PRINT)
SIGNATURE ...
..- -- -. - - _.. - -.. .~'---s. ._- - -~_. - . - ---- - .- -- - .
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'1,\1' -4J; I ~ . /~ (/ 1
NEWYOAKSTATEDEPAATMENTDFHEALTH R ,y n .
Vital Records Section fl
.. '-- -----....-..
Application to.tTown Clerk
for CoPy of Marriage Record
-
...;:;:.).(:,:,\:tt.:.:.::;:=i({::.:.:.::.(.{.(.:;:.;t....::}.:..::..;....:.::::.::........::....::.:;::r!x.~f:.8..::2g....Hs.:s.9B.Q.:...g.~'~:!.~.~g.!?:XS:.!i9.s:.R:;.~gl,.s);:.:;~:..;:;;;;;;:~;;;:::;.;:.::.;,:';:'.::";.:::.:::.;:.:;..:.:':;":.:.::-:';:;'..:..;:.:;..:"'.. ...:..:.;:......
rVl Fee $10.00
~ per copf
A Certificat!on, an abstract from the marriage record issued
under the seal of the Health Department, includes the narres of
the contracting pmlles, thclr rc~illcnw <.Illhe time the hccn:;c
was issued as well as date and plare of birth of the bride 31d
groom.
Search and
Certification
Search and n
Certified Copy W ~c~~~OO
A Certified Transcript includes all of the-items of nformalion
occurring on the original record of the ma'rriage.
A Certification may be used as proof that a marriage OCOJrred.
A Certified Transcript may be needed where prod of
parentage and certain other detailed information rn;ry be
required such as: passports. veteran's benefits, cwrt
proceedings. or selllement of an estale.
.{ii!~:~~'1':::'!i.::~'-!:'::;:j:':::'::!::~:;:'::':i::.::1~:i:;i::i;!;::i:~1::if:!;:;::~:~;:miii'::;::it:pCg:5~E.:te:glt1J)[ETE':.'~'P'~"M}A~:q:'::R.EM'iTfiggg;tf~*ii!mii:p1~1;:~[@!i!~:1i::!..::::!::.
FEES: Make money order or check payable- to Town..of Poughkeepsie.... Please do not send cash or stanps.
There is no fee for a record to be used for eligibilily determination for social welfare or veteran's benefits.
PLEASE PRINT OR TYPE
Name . (First)
of
Groom
Groom's Age
or Date of
Birth
Residence
of
Groom
Date of Marriage
or Period Covered
by Search
Place Where
Ucense Was
a-l~-lo
(County)
(State)
Name
of
Bride
Bride's Age
or Dale of
Birth
Residence
of
Bride
If Bride Previously
Married. State Name
Used at That Time
Place Where
Marriage Was
Performed
(Middle)
(Last)
(First)
(Middle)
"-l
.1(,-C1lo
lD'd6~l \
(County)
~
(State)
~
For what purpose is information reqlired?
rru~ ~~~ L~cu"'\\.~
What is your relationship to person whose record is requesled?
If self, state .self.- ~ \ F
In what cupaclly <.Ire you ilCtlng'!
If allorncy; Name and Icla\lon:;f1.p 0' your chc'll 10 PC' :'0'1:;
whose marriago record is required.
Addre of Ap 'canl
06:)~~~~~ .
~~~~ ~~
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DOH-3D1 (3/93)
(PLEASE SEE REVERSE SIDE)
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WISCONSIN
REGULAR
010: R524-78D6-513O..04 DOS: 09-18-65
Issued: 111-13-414 Ellpifa; ...,....
CIasa En4llU...__ ReRictloI..
D ..... SIIia. bIIcta
Sex Hair ~ Heigjlf ......
F BU). au S'QIt" 1'25
SUSAN ROOIIEY~LD
4141 S WOOIMIllllfllE WAY
APPLETON ....
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3'-~
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. \VISCONSIN 8~~:E
REGULAR 1Ir....
DID: 0243-S5Oe-7337-G1 oos: ....17-67
Issued: 18-13-04 Expir_ "'17-12
Class Endor$emen\$ ~rictioAs
D NoM NOne
Sex Hair Eyes Heig\!It Weight
M BRO.BRO 5,.... 165
MATTHEW J OSWALD
4141S~WAY
APPlE1'f.'lffWl _,,
~ c)&f..J ~.,.>..
Application to Town/City Clerk
for COe>' of Marriage Record
,...,,,,,;:::~i,;:;':!;:;~':~1:i',III~.__J.!l_;::::..:.::::':"
~
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Search and
Certification
r:71 Fee $10.00
L!J per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and p/ace of birth of the bride and
groom.
A Certification may be used as proof that a marriage occurred.
Search and
Certified Copy
D Fee$10.00
per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
proceedings, or setttement of an estate.
~~~~1(~jl~~11j~~~~~~i~i~~1i1~~il!~1i!jfi~j~~~t~~t~~~~~~~1~~11~1~j~f~:~ . . .
PLEASE PRINT OR TYPE
Name (First)
~room bona,\d
Groom's Age
or Date of
Birth
Residence
of
Groom
Date of Marriage
or Period Covered
bSearch
Place Where
License Was
Issued
1~!i~if:~1~j!j~~~~~~i~~!j~~~[~i1~(~i~~f:~i~~~!j~~i~~illI!i~f~~f~~~~~~~~~~~~t~~*I*~[~j;~~::~:~;f'
(Middle)
P cAtt- i c.. k
(Last)
~e. i s ~
3- /lS-6~
(State)
New ~orK
(County)
bv.:tc. h e ~~
10.... ( (- '1 &'
For what purpose is information required?
..Iro~f or tv1ar-r ItAJ~
In what capacity are you acting?
Name (First)
~fride ~+hr y V\
Bride's Age
or Date of
Birth
Residence
of
Bride
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage Was Z i 0 V'I
Performed
(Middle)
Ann
(l.ast)
" e r s O\.(.e..
9-2~ -b~
(County)
Dill iz,hess.
(State)
Ntw YorK
E piSCO pQ.\ ChunJl
What is your relationship to person whose record is requested?
If self, state "self." .s e.. \ F-
If attorney: Name and relationship of your client to persons
whose marriage record is required.
:~~~~jj~1j11l~I~~~!~i1j~1r~~]~~~I~~~~iti~j~~~l~j~~i1~~[~[i~i~~~i~~~~l;!~~j~~r:.
~Jmm~~~jj~~~~~!~lft~~11j~fi~jj~~~~[~~~~~~~j~~j~~~j~~~!fj~~~j~~j~~~j~~jj~~~~Ji~j~~~~~~~~j;
Signature of Appficant
COvfi1/U ~1A- tJ~
Address of A icant
15 Svca.more
POfJij h!<. eefS re
WC{ 1
/Vi
12& 03.
DOH-301 (3/93)
Date f/-u US f 1/
Please pri name and address where record is to be sent.
Ctll+Ay Ne /s~
15 Slj CtA rnore, WOLt
pou h k.~efSlt Nt{ 12."03
2005
1/&
.lt~1i (I
\'~ \ J I)
\Y~r!JY ~.v
\ (V
(PLEASE SEE REVERSE SIDE)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Coey of Marriage Record
:::::::::::::::::::::::::1:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::1:::::::::::::::::1:::1:::::::~:::::::::::::::::::::::::::::::::::::.I:::B:::111181:::111J,11I::::111II1:::1_1:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::1::::::::::::::::::::::::::::::::::
Search and D Fee $1 0.00 Search and ~ Fee $1
Certification Certified Copy 0.00
per copy per copy
A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marriage.
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate.
::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::lll1:U;:::_t!i.1::::BIII:::gl:::lllm:::III:I:::::::::::::::::::::::::::::::::::::::::::::j::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
PLEASE PRINT OR TYPE
Name (First)
of
Groom r 6)}'
Groom's Age
or Date of
Birth
Residence
of
Groom
Date of Marriage
or Period Covered
by Search
Place Where
License Was
Issued
Name
of
Bride
Bride's Age
or Date of
Birth l \ - -;)...:J..-
Residence (County)
~fride :5 w"(clvvOo \) I>> 2-,
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage Was
Performed
(First)
L
(Middle)
(Middle)
(Last)
G
,- ?-5-"'t5
~o
(County) (State)
.Do n +- K-I')() fv..I
(State)
iI_) Q.r-'f' 1-;- C{ I \ .'" t I .
I~SQO
For what purpose is information required?
What is your relationship to person whose record is requested?
If self, state "self."
In what capacity are you acting?
If attorney: Name and relationship of your client to persons
whose marriage record is required.
Date
1- 9 - oS ,"
5 Wi lch.0uocl U.z...
\....)Q 'y ~\l ~-
140
d-Sc..
. 1d-5'to
Please print name and address where record is to be sent.
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Co of Marria e Record
Search and D Fee $1 Search and i]sa Fee $1 0.00
Certification 0.00 Certified Copy
per copy per copy
A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marriage.
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate.
PLEASE PRINT OR TYPE
Name (First) (Middle)
of
Groom
Groom's Age
or Date of
Birth
Residence (County)
of
Groom
Date of Marriage
or Period Covered
by Search
Place Where
License Was
Issued
(Last)
Name
of (\
BridEf""\
Bride's Age
or Date Of) q
Birth
Residence
of
Bride I ~ESS
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage W
Performed
(First)
(Middle)
(Last)
(State)
Id~r~-jq0S
(County)
(State)
f\v ':-/ .
'(a) Iv If;/L (
For what purpose is information required?
What is your relationship to person whose record is requested?
If self, state .seltH '3 (;' ( -J:::
In what capacity are you acting?
If attorney: Name and relationship of your client to persons
whose marriage record is required.
8
Signature of Applicant
- -Q
Date
dress of Applicant
::J..A WI Afrtl!-0P cr
W HPf I NfJ(r2h ~fJ?L 'S ~tJ. / .jSc;O
Please print name and address where record is to be sent.
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
NEWYORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for COe>' of Marriage Record
:::::::::::::::::::::::::i::::':::i::::::::::::::::':::::i:::::,::::::::::::::::::::::::i::i:::i:i::::::::::::::::i:i:ii:ii::i:::i::iiii::::ii::::i:i:::iiij.liiiB:::llllllj::I_IIIII::::IIIII::jllt1:::::::::::::::::::::::::i:::::j:::::::i:::i:::::ij::::::::i::::::::j:::i:::::::::i::i:i::ij:::::::iijii:::,:ii::::::::j:::::::::::::::::::::ji::::::i:i::::
Search and D
Certification Fee $10.00
per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
A Certification may be used as proof that a marriage occurred.
,/
Search and
Certified Copy
ft"/t' Fee $10.00
U per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
proceedings, or settlement of an estate.
:jjj:j:::::::::::::::::::::::::i::ij:i:jij:::jjji::j:::j:jjjjj::jjIii::::::::::::::::::::::::::::::::::::::::::::::iiii::::::::::i:::::::::::::ill_.:::_III.lij:1111::::III:iiljl.llijill.:::::j:iiii::::::::jjijj::::::::::j:iiiijijjj::::::ijiji:iiijijii:::::::jijjjij:j:j::::::ijijijjj:jj:ij:jij:ijj::j:j:::j:::::::::::::::::::::::::::::
PLEASE PRINT OR TYPE
Name (First) .
of I I
Groom ) V
Groom's Age ! I
~~~ate of J ,9- 6/ /9w8
Residence (County)
of l ~
Groom 11(.S....~
Date of Marriage
or Period Covered / /) , ~ {)O 0
by Search (j/ If
Place Where
LicenseWas ~ 'J ~ ;.1
Issued / (A;vl I.iO Wi,
(Middle)
(Last)
& 'lfL-
(State)
(First) (Middle)
Jt~/(4
Name
of
Bride
Bride's Age
or Date of
Birth
Residence
of
Bride
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage Was
Performed
f7f
(County)
Drkks
(State)
A-
IlVtslr~Jk{L, te(y~
For what purpose is information required?
flt:JS PUC2-1
In what capacity are you acting?
What is your relationship to person whose record is requested?
If self, state .self." ~
If attorney: Name and relationship of your client to persons
whose marriage record is required.
Address Qf Applica
( ;)1 LdN (Clk ~DcnL
lAJo I;;~<''?-S P/~ /&r7 ()
DOH-301 (3/93)
Please print name and address where record is to be sent.
(PLEASE SEE REVERSE SIDE)
Application to Town/City Clerk
for Coer of Marriage Record
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section "
Search and 0
Certification Fee $10.00
per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
A Certification may be used as proof that a marriage occurred.
Search and
Certified Copy
O Fee $10.00
per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
proceedings, or settlement of an estate.
PLEASE PRINT OR TYPE
Name (First) (Middle)
of ~'
Groom +1
Groom's Age
~~~ate of d) Jc~.l' ~
Residence? (County)
of . \
Groom D (
Date of Marriage
or Period Covered
by Search
Place Where
License Was
Issued
(Last)
(State)
DY
q1
fJ~
F~UOi1)~~~sr ~r5
In what capacity are you acting?
~ess f!\ A~ca~ / ~,rO l-<51-- i..JJ
rw ~ I\S. ,I0Y J ;;SqO
01')1 (3/93)
Name
of
Bride
Bride's Age
or Date of
Birth
Residence
of
Bride
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage Was
Performed
(First) ·
)€ \ l-r
"0 )61q)1 y
(County)
(~ \ \s
I rlD
rJ~e)
fq llS'
on whose record is requested?
If attorney: Name and relationship Of your client to persons
whose marriage record is required.
Date
(I Jdlos-
Please print name and address where record is to be sent.
(PLEASE SEE REVERSE SIDE)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Cae>' of Marriage Record
Search and D Fee $1 Search and ~ $1
Certification 0.00 Certified Copy Fee 0.00
per copy per copy
A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marriage.
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate.
::::::::::::::::::::::iiji:::::::::::::i:::::i:i:::::::::~::~::::::::::::::::::::i:iiiii:iiiii:::iiiiiii::ii:::i:1::::::::::::::::~:::~::i:::i:i::il..I:::_Bg.l:::IIII:::llli::lilll:i:III:::::1:::::::::::::::::::::::::::::::::::::::~::::::::::::i:i:::::::i::::::::::::i:::::::::::::::::::::::::::::::~:::l::::::::::::::::::::::::::::::
PLEASE PRINT OR TYPE
Name (First)
of J
Groom O~ rt
Groom's Age
or Date of
Birth
Residence
of
Groom
Date of Marriage
or Period Covered
by Search
P.lace Where ,\ , ~
Ucense Was ~;f}[)I{lW~ j' ~ I L
Issued 0 r J ...
(Middle)
S 'D~
(Last)
Name
of
Bride
Bride's Age
or Date of
Birth
Residence
of
Bride
If Bride Previously
Married, State Name J~
Used at That Time l1e...! 'Je
Place Where
Marriage Was () h i / ,?
Performed rC)I)j J "'h. t' J ~
(First)
/) f) lJ~\~
~3)2/(P-5
(Middle) (Last)
P ''J)/ I? () bbo
(County)
~J) ,,)-kJe.,~
(State)
iVY
(County)
Dvlhf~ ~
(State)
NY
Ie )q /05
?: '0 Vi ~"-7.:l0
Ni
NY'
For what purpose is information required?
mv:.:.+ l1;"ve ('.f l ,t'J;-rj' (~/U\ ~{
l( (e...!0-1..f.J, f \~f. \
What is your relationship to person whose record is requested?
If self, state .self.. .JeJ.f
In what capacity are you acting?
If attorney: Name and relationship of your client to persons
whose marriage record is required.
Siji!nature of Applicant
Date ! /
'J/IJ/05
Please print name and address where record is to be sent.
ff)( ~ ((),~ -\o.seet\ '1)\ \2-,ubbo
/5.1JK ~.oJQ ~ Qpr It
~ ~ \;J \ i" RL\ c.-'b N'I I j51 0
~ r~~
,,\O..p.)(!!3E SEE REVERSE SIDE)
DOH-301 (3/93)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Coer of Marriage Record
Search and D Fee $1 Search and D
Certification 0.00 Certified Copy Fee $1 0.00
per copy per copy
A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marnage.
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate.
PLEASE PRINT OR TYPE
Name (First) (Middle) (Last) Name (First) (Middle)
of ~/Ilf/S of
Groom ride
GrOOm'SAg~ Bride's Age
or Date of I or Date of
Birth - Birth j
Residence (County) Residence
of d of
Groom Bride
Date of Marriage If Bride Previously
or Period Covered Married, State Name /U /f/
by Search Used at That Time
Place Where Place Where
License Was e,.J r1 ~ f) ,J (" f (l5 fALLS tV.y. Marriage Was
Issued Performed uJlir'P I":; b 6,e S.
(Last)
),Ji:'
(State)
641- 1., .5 #, Y.
For what purpose is information required?
What is your relationship to person whose record is requested?
If self, state "self."
s ,,; L.~
AfpL)'flvC. f()f?. /JOY<) 51E1? i1)(!~
C~I'/ N e ~-rJ5yJ /3EflJi flT~
In what capacity we you acting?
~J.~
If attorney: Name and relationship of your client to persons
whose marriage record is required.
L/ /t)
Date
of Applic
LS '}- r ~o5 (3ticf'
fr1 D i?G".;'A rv, y.
tJr
Please print name and address where record is to be sent.
51:
f Z <)" i-J ()
~I CJC t$.0
LYP
CE.\\JE.O
lU~ 111\)~
10'J'J~ C\..E.R"
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
Application to Town/City Clerk
for COe>' of Marriage Record
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Search and g]
Certification ..- Fee $10.00
per copy
'"
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
Search and
Certified Copy
O Fee $10.00
per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
A Certification may be used as proof that a marriage occurred.
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
proceedings, or settlement of an estate.
PLEASE PRINT OR TYPE
Name (First) (Middle) (Last) Name (First) (Middle) (Last)
of Pet A Jq; (Joe ,qflJt l of PCt
Groom I yJ r.- /) Bride h . I f\1 iJ~ i1~"''(~ / r
\...... I ( &; t, t--r )
Groom's Age I Bride's Age I
or Date of ?/; ;h t or Date of /J ;;
Birth Birth / {j r
Residence (County) (State) Residence (County) (State)
of ~ Yul of ;'(.J-~
Groom iJv.- ~t c S" J f~w Ie Bride 0... S S IV f. ......i "-j"l Ie.
Date of Marriage If Bride Previously
or Period Covered V/;/ Ii ) Married, State Name
by Search Used at That Time
Place Where Place Where
License Was II, Marriage Was "" h ,'1)
Issued ~\J ~.;'J.P wC,el ) ft. ,r..J'1 Performed S 7 f'rtw t...r rtI ~ 1"" '-1
For what purpose is information required? What is your relationship to person whose record IS requested?
Jrv.J If self, state "self." S r f
l....lt. (\.~ c': 'f: 't:
In what capacity are you acting? If attorney: Name and relationship of your client to persons
whose marriage record is required.
Signature of Applicant Date
/"1.?- ~ 6';5.7 h r
Address of Applicant Please print name and address where record is to be sent.
PiA t.. I iJ-t 19't'5 z I, '}
I l. ) 11 t- 1 /....;- 1"1 /6 ""'t / Z s - '1 1- / ~ ( 1 '1 r q 1..J 111 Ii {> /u ~ '1 / l f Y' l-
I l.- I WD (.. /
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
RECE\VEC
JUN l 72005
TOWN CLERK
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Col!}' of Marriage Record
Search and D Fee $1 0.00 Search and D Fee $1
Certification Certified Copy 0.00
per copy per copy
A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marriage.
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate.
PLEASE PRINT OR TYPE
Name (First) (Middle) (Last) Name (First) (Middle) (Last)
of P(111. \) L." ~ of IYt! \d-.J ~. ,
Groom L 1'\(" ~\ ') Bride V I 0-- nCOYle \~ I
Groom's Age Bride's Age
or Date of 5 - \ d-.- \o~ or Date of to I (0- I q -, 0
Birth Birth -
Residence (County) (State) Residence (County) (State)
of \..;~\S\E'L 0 '-I of u\ (\~1
Groom Bride ~ 1E'L
Date of Marriage If Bride Previously -'
or Period Covered ~ \~S \ q 9 Married, State Name
by Search Used at That Time
Place Where Place Where
License Was Wa pp I N We Marriage Was
Issued Performed
For what purpose is information required? What is your relationship to person whose record is requested?
If self, state "self. .
\ ()'Su..n::l () c.Jl..-t Sp ~ v:
In what capacity are you acting? If attorney: Name and relationship of your client to persons
whose marriage record is required.
'"'- y;{~o:A:c~nA ~. Date
-~ 6 -/7- 06
Aadress of AP~tn0J Please print name and address where record is to be sent.
~! I< nOLi-< ~
-
(!lLn-mr1c{ftU n!J I d,6 J '::)
I
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town Clerk
for Co of Marria e Record
....................
. . . . . . . . . . . . . . . . . . . .
....................
....................
....................
. . . . . . . . . . . . . . . . . . . .
................. ..
.... .. ..... ...... ...... .......
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.................................................
. ............................................
.................................. ..
......................
...................."...........
.................................
.................................
.................................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
...........................
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...................
. . . . . . . . . . . . . . . . . . .
......................................
...................
. . . . . . . . . . . . . . . . . . .
.................................................................................................................................................
)))m....M':..e..::s.::::oe:...:::..:":.II:.:S::.S.:;:>S:;:>1I::o;;.=:::.;:;:s"':':':'.""'II"':':":s"::'o"::)I:::O':;::1"':::::'.':::::;'0.'::::::1(::::/0':':'0':::::::.::::::)':'::)))
................ .. . .. ..... ..... ... .. ....... . .".". ..... . ......
:::::::::::::;;:;:::::;:::;::::::.::::;::.:;:;:.:::::::.:.:.::;:;;:::::.:::::.:::::::::.:::::.:;:.:.:.::;::.:.::;::::.::::;.:=:::-:::.:.::::;::;:.:.:::::::.;.:.:::::.:::::.:::.:::.:::.;.:.:.:.:.:.::::;:::..::::.;::::.:=:.:::;:.::::;.;::::.:::.::;:;:;::.::::;.::;.::;::.:::.,;:::::::;::::
.............................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
........................
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...............................
.......................................................'.'
. . . . . . . . . . . . . . . . . . . .
Search and D
Certification Fee $10.00
per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
A Certification may be used as proof that a marnage occurred.
.....................
....................
.........................................
.....................
Search and
Certified Copy
E1
Fee $10.00
per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
proceedings, or settlement of an estate.
..........................
..........................
...................................................
.......:...;.;.:.:-:.:.:-:-:.:.:................... ......
....... ...... ..... ...... ......
......................................
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. . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
. ....................
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. .. .. ....... ... ......... .. ...... .... .....................
. .. ... ...... ........ ...... .. ..... .....................
-: ....: ..... ..' . ...:.:-'. '.' . ....: ..... ....::.: ....;.: ..... ..... .:.: ..... :.:. '.:'" ..: :.:.;. ..... ... ...;.:.;.:.;.:.:.:.;.;.:.:.:.;.:.;.;.:.;.:.;.
:;:-::;:;::.:.:.:::.:.;.::;.:::::.:::.;.::;::.:.:.::;:;:::;.:::::::.;.:::::.;.:.;.;::.::;:;::.:.:.;.:.:.:.::;::-:;;::.:.:.:.;:;::.:::::::::.;.;:;::.;::.;:;.:::.;::.;::::.::;:;.:::.:::.:::-:.:.::;:;::.::;::.:::.:.:.:::.::;.:.::;.;::::.;:;:;:::;.:::::::.:.;.:::.:.:.::;:;:;:;;::::::::::;::::::;::::;';':""':
...... ............... .....................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.............................
..................... .....
. . . . . . . . . . .. .. ..
............................
. . . . . . . . . . . . . . . . . . . . . . . .
.................
FEES: Make money order or check payable to New York State Department of Health. Please do not send cash or stamps.
There is no fee for a record to be used for eligibility determination for social welfare or veteran's benefits.
PLEASE PRINT OR TYPE
Name (First) (Middle) (Last) Name (First) (Middle) (Last)
of of
Groom ~E Bride ~ ..:> <::::r::"'S L.veJ(\
Groom's Age Bride's Age
or Date of or Date of
Birth -S \"'(s ":( Co Birth
Residence (County) (State) Residence (State)
of of K
Groom c-~~~ \'\ Bride Du\Ck~
Date of Marriage If Bride Previously
or Period Covered 4\\~\o-<) Married, State Name
by Search Used at That Time
Place Where Place Where 0J "-' ~'i ~ C \\\")K-
License Was Marriage Was
Issued Performed \...0~~~""S
For what purpose is information required?
C \\CtJ'{\~
5S~,c~
~ ~QcJC:\
0\'\ Q~Q..
'~ DL-
In what capacity are you acting?
What is your relationship to person whose record is requested?
If seW, slate "self." S. ~ ~
)
If attorney: Name and relationship of your client to persons
whose marriage record is required.
Signature of Applicant Date
, CX'l\-C- ~~\ 0\.9-.
Add ss of Applicant Please print name and address where record is to be sent.
S\t- \r'Il~ ~
~~~~~ ~ 'It--:>'" \')<)-10
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
YS-34M
-
.;
..;
j
TOWN CLERK
TOWN OF WAPPINGER
20 MIDDLEBUSH ROAD
WAPPlNGERS FALLS, NEW YORK 12590
08459
RECEIV~ROM ~~-,J" t~ j)~
~~~~ -
FOR _ j"j ~"';.h fL/,( ~
g CASH ~ f:JbtmkCYOU
o CHECK BY I -" /....,~ '
o M.O.
DATE~
$~
DOLLARS
AMOUNT OF ACCOUNT
THIS PAYMENT
BALANCE DUE
..
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
'.
Application to Town/City Clerk
for COe}' of Marriage Record
.' ---...
Search and Search and /' tzl 0.00 '\\
Certification D Fee $1 0.00 Certified Copy Fee $1
per copy per copy
A Certification, an abstract from the marriage record issued A Certified Transcript includes all--of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marriage.
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate.
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::_R:::_lmuli1IBI:::111:::1111:::.11::::::::::::::::::::::::::::::::::::::::::::::::~:::l:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
PLEASE PRINT OR TYPE
Name (First)
of 0,
Groom c... '( ,
Groom's Age
or Date of
Birth
Residence
of
Groom
Date of Marriage
or Period Covered
by Search
Place Where
License Was
Issued
(Middle)
(Last)
~V
L
~1'5J~:;
(State)
",
\ -~..
\..J
61
60
Name First) \- (Middle)
~fride W 4 f lc\{,
Bride's Age \
~~ate of llll{} Co
Residence (County)
~fride DGJc ~S 5
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage Was
Performed
(State)
'\0\
Jr7fPr S'
our-J
What is your relationship to p on whose record is requested?
If self, state "self."
In what capacity are you acting?
If attorney: Name and relationship of your client to persons
whose marriage record is required.
Date
~
3~
Please print name and addr wher record is to be sent.
L~~ue l~\(Q~
)
(PLEASE SEE REVERSE SIDE)
,.
NEWYORK STATE DEPARTMENT OF HEALTH
Application to Town/City Clerk
f C fM. R d
Vital Records Section or opy 0 arnage ecor
Search and D Fee $1 Search and D Fee $1 0.00
Certification 0.00 Certified Copy
per copy per copy
A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marriage.
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate.
PLEASE PRINT OR TYPE
Name (First)
of
Groom
Groom's Age~
or Date of P
Birth
Residence
of
Groom
Date of Marriage
or Period Covered
by Search
Place Where
License Was f1J,A!Op/a..ae/f( fV1
Issued rv.. P /
(Middle)
(Last) ,
g;q
o
(County)
7""G ~
(State)
ch.e~
/I/V
(First)
(Middle)
'e
Name
of
Bride
Bride's Age
or Date of
Birth
Residence
of
Bride
If Bride Previously
Married, State Name
Used at That Time
Place Where "
Marriage Was -As h lu L{
Performed .I
J
L"
~
~~
(County)
(State)
,Du
s
N
IVy
For what purpose is information required?
C~ Wtf
In what capacity are you acting?
What is your relationship to person whose record is requested?
If self, state .self." &;-(1
If attorney: Name and relationship of your client to persons
whose marriage record is required.
1dv.~<v
Address of Applicant 12... k -
sq /JYC{) .~h \ Vi Dr.
\,/\j Ce-if ( c2--t/t-\-o {\ tI A a D I ~~
DOH-301 (3/93)
Date
~-I J -05-
Please print name and address where record is to be sent.
(PLEASE SEE REVERSE SIDE)
"
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Coe.v of Marriage Record
:::::::::::::::::i:::::::::::::::::::::::::::i:::::::::i:::i:::::::::::::::::i:::i:::i:::::::::::::::::::::::::::::i::::::::::::::::::::::::::::::::::::::::.I:::.:::IIIIII:i:lilll_:i::~glll:::liI):::::::::::::::i:::i:::::::::::::::::::::::::::::::::i:::::::::::::::::::::::::::::::::::i:::::i:::i:::::::::::::I:::::::::::::::::i:i:i:i:i:i::::::::::::::
Search and D Fee $1 Search and GJ Fee $1
Certification 0.00 Certified Copy 0.00
per copy per copy
A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marriage.
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate.
::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::I:::II::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::..:111:::_1111.:::1111:::111:::1111:::1;1:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
PLEASE PRINT OR TYPE
Name (First)
of .____
Groom
Groom's Age
or Date of
Birth
Residence
of 0
GroOm ,~~ve
Date of Marriage
or Period Covered
by Search
Place Where
License Was .- -,",.f
Issued j OW,.; v
(State)
IVV
Name
of --
Bride tit r J\
Bride's Age
or Date of
Birth
Residence
of
Bride 0 r .",v~ e.
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage Was /)
Performed r 0 \)
(First)
(Middle)
L (\IN
(Last)
Ii Jki.JJ
f(c..JyV
;3 - ~ - 7 (/
(County)
~ -so -73
(County)
(State)
(V
0; - ). -0 I
w.-
If" {j j
S,t!
IVy
For what purpose is information required?
RJ !}fh'IJ" fJpp lie" I-,'orl
, . I
What is your relationship to perSon whose record is requested?
If self, state .self.. 5e / P
In what capacity are you acting?
If attorney: Name and relationship of your client to persons
whose marriage record is required.
Signature of Applicant
Date
L-/-J-) -0,)-
Please print name and addr
\)
~. ~
Address of Applicant
;r / I<;Jf\C (< J
~ d
;J?Or'tj () M (' "i- (\J Y
)J-s lIt .'
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ,
Application to Town/City Clerk
for Co of Marria e Record
Search and D Fee $1 0.00 Search and D Fee $1 0.00
Certification Certified Copy
per copy per copy
A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marriage.
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate.
::::::ttt:r:t:rrrrr:t=::::::::::rrrrrrrrrrrr::rrrrrrrr__'E":':'::::jJ.ijtU6j:t_s"':':;:)ibiBij:::::.:il$rn_ij'm"':;"'::IifS'.:':':S":':':r:::::::::::::::::::n::::::::::::::::::r::::::::::::::::::r::::::::::::::::::::::rrrrrrrr::::::r:::::::::::::
PLEASE PRINT OR TYPE
Name ( First) (Middle) (Last) Name ( First) (Middle) (Last)
of of
Groom Bride
Groom's Age Bride's Age
or Date of cg -to _c Ie,S or Date of J-f-I/-7fo
Birth Birth
Residence (County) (State) Residence . (County) (State)
of 'J) U. fc~s.s Nt of lli -1 (. f^--l SS NF
Groom Bride
Date of Marriage S 17, :1CO.v If Bride Previously
or Period Covered . e. f> + Married, State Name LO t; $)ci do-
b Search Used at That Time
Place Where Place Where
License Was Marriage Was
Issued Performed
For what purpose is information required?
What is your relationship to per, on
If self, state "self."
In what capacity are you acting?
Date
f App. ant
iY4 1;^e jet C,: rc tL . __ ~
viupp itl' rs. F'o Us NY / ;~ S 7 (J
Please print name and address where record is to be sent.
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for COe)' of Marriage Record
Search and D Fee $1 Search and D Fee $1 0.00
Certification 0.00 Certified Copy
per copy per copy
A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marriage.
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate.
PLEASE PRINT OR TYPE
Name (First)
of '7 ' +
Groom 1(0 ~l""'
Groom's Age
or Date of
Birth
Residence
of
Groom f.Jo\~ ruL..v.-
Date of Marriage
or Period Covered
b Search
Place Where
Ucense Was
Issued
(Middle)
AH~v\
(Last)
+-\rc\krl
17. (~\ ( 11b"
(State)
L\t.J~~~ tuw Oft\
(County)
G/-=r{Zco3
r..J-Wi'J ~\- uJ h?jJ-~1. r- AU-)
(First)
(Middle)
(Last)
&VC-J1. L'f( <vU..
Name
of
Bride M~
Bride's Age
or Date of
Birth
Residence
of
Bride
If Bride Previously
Married, State Name
Used at That Time
Place Where
Marriage Was -- . . f
Performed luw)) ,~ lNM"'DJJ.c-y... PA-~
AM) (l. cA
.f A\-t ll1-3
(County)
(State)
lL
For what purpose is information required?
~ C'e.J'-1~ lvtP.{'f'.,"t'\jIi!..~ ~Mc-t~
QudW .=t.~ (Aju; ~I\~)
In what capacity are you acting?
,;v.... ~ w JV\.-
Sign01icant
Address of Applicant
I )' ~J.. ~ CJ~
Nch\J .'c..M ( }.JJ ~u\ ~ cJ Z~ q/u J
Uvt.l--eJ oJ'~
DOH-301 (3/93)
What is your relationship to person whose record is request7'1?
If self, state "self." 15' \
Jj ,p. Cb~
If attorney: Name and relationship of your client
whose marriage record is required.
'y~d< lAp
(PLEASE SEE REVERSE SIDE)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Col!}' of Marriage Record
Search and D Fee $1 0.00 Search and [Z] Fee $1
Certification Certified Copy 0.00
per copy per copy
A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marriage.
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marrrage occurred. proceedings, or settlement of an estate.
::~:::::::::~~::~~~~~~~::::~:::~::::::::::::::::::::::::~:::::~:::::::~~::::~::~::~:::::::::::::::::::::::::~~::~~::::~::::::::::::::::::::::~:::::lg_.:::_Rg_.~~:I.I::::III:::IIII:::III:::::::::::::::::::::::::::::::~~::::~:::::::::::::::::::::::::~~:~~~~~~::::::~~:::::::::~:::::::::::::::::::::::~:::::::::::::::::::::::::::::::::::
PLEASE PRINT OR TYPE
Name (First)
~room jQ H,J
Groom's Age
or Date of C6"\ 1Jt..'-
Birth 01/ " :.,.)
Residence (County)
of ~
Groom J}\)TLH C.s,s,
Date of Marriage
or~enod Covered Hit/!..LN d ~~ I qqq
by Search ' !
Place Where
~~~~e Was 1D0rJ ()f N,.4fnrJ~r0
(Middle)
L
(Last)
'fA fGrU::LL
(Last)
P;C.<ELl
(State)
Name
of
Bride rY/J (j 1/
Bride's Age
or Date of
Birth
Residence
of
Bride
If Bride Previously
Married, State ~ame ~rN (I A
Used at That TIme / n
Place Where
Marriage Was N04IJ v \ \ j
Performed ^-) rv y
( First)
(Middle)
4-9 Jj~::;:'.
. !
N
(County)
j))TCHES. ~
(State)
^J l/
("0 tVNo;(
What is your relationship to person whose record is requested?
If self, state "self."
StLr
In what capacity are you acting?
,SfiOUS6'
If attorney: Name and relationship of your client to persons I
whose marriage record is required. . J
~.,~r
Signature of licant . /' '. 1
i ~t/CL _ fC'l~{eU'
Address ~pplicant ') /,";
7il JIll) ;ttrl Cl D C r
f()ill!7 H leCtP } t::
rJY J 2lY(7~
Date
\
Please print name and address where re
J
~;
DOH-301 (3193)
(PLEASE SEE REVERSE SIDE)
\
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town Clerk
for Coey of Marriage Record
...............................
...............................
...............................
...............................
...............................
...............................
...............................
...............................
............... .
.................
.................
.................
.................
.........................
.......................... .......... ......
. ...................... ......................
.. ............... ......................
..... . ..' .... .
.:..:rnlll:II.I:lglg:lgl~OIII::~:tll:IBI:::I.i~::::...~:::::~::~.::~:~:::::::::~~~:~:::::::::.. ...:.:.
Search and D
Certification Fee $10.00
per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
A Certification may be used as proof that a marriage occurred.
Search and
Certified Copy
D Fee $10.00
per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
A Certified Transcript may be needed where proof of
parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
proceedings, or settlement of an estate.
. . . . . . . . . . , . . . . . . .
..................
..................
..................
..................
..................
:..:I:_I:':I_IIIII:.:.IIII~~i'IRI:i::I:llli.:III~.:i:.:i~i:i~.:::i~ii.i...i.::.:.:
.....................
. . . . . . . . . . . . . . . . . . . . .
.....................
............... ...
............... .................
................................
................................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.................................
. . . . . . . . . . . . . . . . . . . . . . . .. .. .
.......................
. .. .. .
...............................
...............................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
...............................
..........................
. . . . . . . . . . . . . . . . . . . . . . . .
FEES: Make money order or check payable to New York State Department of Health. Please do not send cash or stamps.
There is no fee for a record to be used for eligibility determination for social welfare or veteran's benefits.
PLEASE PRINT OR TYPE
Name (Fir~ (Middle) ('ist)
~room 6r~ ;/. C6/~
Groom's Age .
~r~ateof II / '6/51?
Residence (County)
~room ;)~Jf t
Date of Marriage
or Period Covered /1 :;;L <
by Search If. I tJ
Place Where
License Was
Issued
(State)
For what purpose is information required?
In what capacity are you acting?
(Middle) (Last)
r /OL--r r 11 //)}
Name (First)
of /" ;/
BrideL-l.1 vI""\."
Bride's Age
or Date of
Birth
Residence
of
Bride
If Bride Previously
Married, State Name
Used at That Time
Place Where ;0
Marriage Was S; "- /
Performed 0 fA '1
told-s/~:)
(State)
/l(
(County)
~VC
What is your relationship to person whose record is requested?
If self, state "self."
If attorney: Name and relationship of your client to persons
whose marriage record is required.
Signature of Applicant
Address of Applicant
DOH-301 (3/93)
Date
Please print name and address where record is to be sent.
(PLEASE SEE REVERSE SIDE)
YS-34M
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Col!}' of Marriage Record
~
Search and
Certification
Search and
Certified Copy
D Fee $10.00
per copy
A Certification, an abstract from the marriage record issued
under the seal of the Health Department, includes the names of
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and
groom.
A Certification may be used as proof that a marriage occurred.
r:-/f Fee $10.00
~ per copy
A Certified Transcript includes all of the items of information
occurring on the original record of the marriage.
A Certified Transcript may be needed where proof of . \ ~
parentage and certain other detailed information may be It~ f ~
required. such as: passports, veteran's b. enefits, ~}rrt O~ r 0 \.,
proceedings, or settlement of an estate.f\ ~ i 0 A
Ilr
PLEASE PRINT OR TYPE
Name (First) (Middle) (Last) Name (First) (Middle) (Last)
of :SD ~V\ s.~6...I\ ~c,,-\\ of \4e_\en Lu.tvv"'~ ~ s.~.L..-cAJ ~
Groom n Bride
Groom's Age \ Bride's Age '2-~
or Date of '2. I 3 \ CJ \{ ~ or Date of S\Z-4-l1 ~
Birth Birth
Residence (County) (State) Residence (County) (State)
of I Po..<::::,. C- D of E I PiA C!- O
Groom E C Bride S.O
Date of Marriage , 1 If Bride Previously
or Period Covered Lo I~ D Y- Married, State Name
by Search Used at That Time
Place Where Place Where
License Was F W ~~\ ""',\<4's. Marriage Was f O\A.~,,^ \( e.e{A I e D y
Issued TDWY\ 0 Performed f
For what purpose is information required? What IS your relationship to person whose record IS requested?
c.JA If self, state "self. . ~~\~
~vA..fL ~<;je
In what capacity are you acting? If attorney: Name and relationship of your client to persons
~'< . oA Q... whose marriage record is required.
"-
~nt~D ~ Date } ~ \
M ~ \ 0 ~
Address of Applicant d V ~ Z" Please print name and address where record is to be sent.
z..4-~lc (~D W z-z- \-\e...\~ n o-r ~"'- \ \ t:L
~\oJ'O\cl 0 \,r'~<;'1 Qo ~q 2-0 2-4- ~\o e. a,~ - Vl,..) 22%'
Co \ t;)v ^- JD . ~",",- ^~~I C-o roo, 2 D
l!")
DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
'"
Application to Town/City Clerk
for Co of Marria e Record
.:
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Search and D Fee $1 0.00 Search and D Fee $1 0.00
Certification Certified Copy
per copy per copy
A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marriage.
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate.
PLEASE PRINT OR TYPE
Name (First) (Middle)
of ._ "
Groom ~,tilr\ .,-\"t ~).<
Groom's Age
or Date of
Birth
Residence
of
Groom \
Date of Marriage
or Period Covered
by Search
Place Where
License Was
Issued
,\J\ .
Name
of
Bride ~.. 'f c.. rQ.:x-:
Bride's Age
or Date of
Birth
Residence
of .
Bride 'L-J,-~-\ ( V\ c;..~ ":.:>
If Bride Previously
Married, State Name
Used at That Time
Place Where """~ ~ ~, " r'- ~
Marriage Was . :)
Performed () 4.... r', .-' \ ~<: L\-S.
(First)
(Middle)
(Last)
,\;\~ \~ \~"
(Last)
(State)
N- '--
(State)
N"
What is your relationship to person whose record is requested?
If self, state .self." ~_ >, \ {:2
~" ...;;Q.
For what purpose is information required?
. '" .
L\ .. , (-.~~ - \:::--',\......
r \ \,,- ',~ -'---..)" \ J
~
In what capacity are you acting?
c. - ~~ \ \::
If attorney: Name and relationship of your client to persons
whose marriage record is required.
'-2,
'---""
-
D'-:>
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Address of Applicant
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(PLEASE SEE REVERSE SIDE)
Date
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Please print name and address where record is to be sent.
DOH-301 (3/93)
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Application to Town/City Clerk
for Co of Marria e Record
Search and ~ee$10.00 Search and D Fee $1 0.00
Certification Certified Copy
per copy per copy
A Certification, an abstract from the marriage record issued A Certified Transcript includes all of the items of information
under the seal of the Health Department, includes the names of occurring on the original record of the marriage.
the contracting parties, their residence at the time the license
was issued as well as date and place of birth of the bride and A Certified Transcript may be needed where proof of
groom. parentage and certain other detailed information may be
required such as: passports, veteran's benefits, court
A Certification may be used as proof that a marriage occurred. proceedings, or settlement of an estate.
PLEASE PRINT OR TYPE
Name (First) (Middle) (Last) Name (First) (Middle) (Last)
of ' . rb~4h)yY\ of fin HJ//q(.
IV sf
Groom ' Bride
Groom's Age Bride's Age
or Date of '6- /- )-L or Date of )"-C-s-
Birth Birth
Residence (County) (State) Residence (County) (State)
of of b ft:. A-:" .5:',>. AI
Groom Bride
Date of Marriage If Bride Previously
or Period Covered Married, State Name -----
by Search Used at That Time
Place Where Place Where
License Was - Marriage Was N0
Issued Performed
What is your relationship to person whose record is requested?
If self, state "self." S ~ I C
In what capacity are you acting?
If attorney: Name and relationship of your client to persons
whose marriage record is required.
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Date
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Please print name and address where record is to be sent.
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DOH-301 (3/93)
(PLEASE SEE REVERSE SIDE)
St.andar: Form 85P
Revised September 1995
U.S. Office of Personnel Management
5 CFR Parts 731 , 732, and 736
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V.SccrJP~>' .
UNITED STATES OF AMERICA
4/Y -)tr /- -j? d-)9' Y
AUTHORIZATION FOR RELEASE OF1NFORMATION
Form approved:
O.M.B. No. 3206-0191
NSN 7540-01-317.7372
85-1702
Carefully read this authorization to release information about you, theI:l sign and date it in ink.
I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal
agency conducting my background investigation, to obtain any information relating to my activities from
individuals, schools, residential management agents, employers, criminal justice agencies, credit bureaus,
consumer reporting agencies, collection agencies, retail business establishments, or other sources of information.
This information may include, but is not limited to, my academic, residential, achievement, performance,
attendance, disciplinary, employment history, criminal history record information, and fmancial and credit
information. I authorize the Federal agency conducting my investigation to disclose the record of my
background investigation to the requesting agency for the purpose of making a determination of suitability or
eligibility fora security ,clearance.
I Understaildthat, foifmancial or lendiriginstitutions,medicalinstitudons, hospitals, health care professionals,
and othersouices ofiriforimition, a separate specific release will be needed, and t may be contacted for such a
release at a later date. Where a separate release is requested for information relating to mental health treatment
or counseling, the release will contain a list of the specific questions, relevant to the job description, which the
doctor or therapist will be asked.
I Further Authorize any investigator, special agent, or other duly accredited representative of the U.S. Office
of Personnel Management, the Federal Bureau of Investigation, the Department of Defense, the Defense
Investigative Service, and any other authorized Federal agency, to request criminal record information about
me from criminal justice agencies for the purpose of determining my eligibility for assignment to, or retention in
a sensitive National Security position, in accordance with 5 U.S.c. 9101. I understand that I may request a
copy of such records as may be available to me under the law.
I Authorize custodians of records 'and other sources of information pertaining to me to release such
information upon request of the investigator, special agent, or other duly accredited representative of any
Federal agency'authoiizedabove regardless ofaIiy previous agreement to the contrary.
I Understand that the information released by records custodians and sources of information is for official use
by the Federal Government only for the purposes provided in this Standard Form 85P, and that it may be
redisc10sed by the Government only as authorized by law.
Copies of this authorization that show my signature are as valid as the original release signed by me. This
authorization is valid for five (5) years from the date signed or upon the termination of my affiliation with the
Federal Government, whichever is sooner.
Signature (Sign in ink) ~ Full Name (Type or Print Legibly) Date Signed
1J~ r< W\tU~1'f\ R\J~~ ~t:)l'f\u~ l\ / Olf} OLj
Other Names Used fi Social Security Number
~\tL ~~V~ )1Y-f ...4 t'3-"3qse
Current Address (Street. City) ~SM\4 \.\.. State ZIP Code Home Telephone Number
~CIS -S-€<<..fRs.~ ~WD 'Ny J ~ 'Sf).. t.f (Include Ares Code)
( f6~ f6Cfl.L>- Oto'B7
Page 8
TOWN CLERK
TOWN OF WAPPINGER
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NEW YORK 12590
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08109
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DATE / //" /~.3
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AMOUNT OF ACCOUNT
THIS PAYMENT
01. ( oL"" --
S69 sa7 1781
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MARl'< i MILLER
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