139
+
~
U)
w
Ill.
9
::l
o
:I:
U)
Z
o
~
i,;
w
a:
w
~
~
a:
~
l!;
5
Ii:
~
a:
w
o
w
a:
w
i
lZ
w
a:
o
o
<
?L
hi
lL
U)
cr.'
!
:>
z
o
~
W
~
w
-en
z
-w
(.)
- ::i
+
~~~
ffi~~
a:~_
t-wZ
U)...:::l!
::lolil
:::l!(!)i5
!z;::;Ul
~~15
~~~
..w(!i
j!!!2lt)
o~z
z::;_
Dutchess
COUNTY
Wappinger
CITYITOW~
DISTRICT 368 '
NUMBER
REGISTER 1 j~
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Andrew James Clay
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sharon Montefusco
1. A. FULL NAME
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
lL
'"
12501
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL- SEE REVERSEtlOj-oo-l ~ 1 8
D. SOCIAL SW NUMBER Dutchess
12, RESIDENCE A, B.
(STATE)~ (COUNTY)
C. CHECK Otli .0 C.I1Y . TOWN 0 VILLAGE
AND t"ougm<et:J.I e
SPECIFY 12 E.~~t:x Rd. 12801
D. STREET ADDRESS ZIP .,.
E. IS RE!gNCE WITHIN LIMITS OF CllY OR INCORPORATCftt'ILLAGE? ?O 0 YE~'97~O
13. A. AGE 3B. DATE OF BIRTH L.. L
MONTH DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEl060-70-1242
D. SOCIAL SECUW NUMBER
2. RESIDENCE A. N B. Uutchess
(STATE).L (COUNTY)
C. CHECK ONIi-.. 0 .,CITY 1] . TOWN 0 VILLAGE
~~~CIFY I"'oughl\eepsle
12 E:ssex Rd.
D. STREET ADDRESS ZIP
",
Y/ rrnrr9
YEAR
l-
S;
c(
c
Ii:
~u.
c(
E. IS RESIDENCE WITHIN UMITS OF CllY OR INCORPORATED ~~GE? 2fP
3. A. AGE 40 3B. DATE OF BIRTH /
MONTH DAY
4. EMPLOYMENT
A, USUAL OCCUPATION Carpenter
B. TYPE OF INDUSVlY OR B~INESS l,;onstuctlon
5. PLACE OF BIRTH Mount ISCO, Ny
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Edward R. Clay
B. COUNTRY OF BIRTH U ~ A
7. MOTHER h' K k
A. MAIDEN NAME Kat enne ec er
B. COUNTRY OF BIRTH Ge;many
8. NUMBER OF THIS MARF,lIAGE
Barbara Ann Cataldi
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH 2
18. NUMBER OF THIS MARRIAGE
14. EMPLOYMENT
Bar Tender
A. USUAL OCCUPATION H 't n
B. TYPE OF IND~ahllH~'f81i~~ O~pl a I Y
15. PLACE OF BIRTH Y
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER Ronald Nicholas Montefusco
A.NAME USA
B. COUNTRY OF BIRTH
17. MOTHER
19. ~~~~~~~RM~FR~~"E<tIf~us MARRIAGES WHICH ENDED BY
OI~ORCE CIVIL A'tjULMENT
.,.
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEAJf1 B. HOW DID LAST MARRIAGE END? (3) 0 DIVORIf2 (3) D~ULMENT 2cfd5 DEATH
C, DATE LAST MARRIAGE ENDED? MONTH / DAY / YEAR C. DATE LAST MARRIAGE ENDED? MONTIV / DAY .( YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
~
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY. IF NOT USA) SelF SPOUSE (~~~it2o~ p6cagKflY<~esp~~~ufQy' IF NOT USA) SELF SPO~E
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
f my knowledge and belief that the information I prDvlde~s true and t clare that no legal impediment ists
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~CE CIVIL AN~LMENT
Dee,TH
DE()TH
23, SUBSCRIBED AND SWORN TO/AFFIRMED F.
SIGNATURE OF TOWN OR CITY CLERK DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~t1 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.J CI,.ERK M t rson 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) nn. as e
{. TIME MONTH YEAR MONTH
SEAL SIGNATURE ~
MAI':m M~ 12 09 2009 02 06 2010
'-v-I
YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON T
DATE AND AT THE TIME 0
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCUR~ _
A. STATE NEW YORK B. COUNTY d;iv.. I , ~
C. LOCATION OF CEREMONY
(CHECK ONE AND S IFY)
PS~
NAME (PRINT) ·
SIGNATURE~ .
nc.