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1 . A. FUll NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Jamst~lratrick R~~R~& SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
COUNTY Dutchess
CITYfTOWN Wappinger
~~:~c:1368 .
~5~I:J~R136
..
F;j
B. BIRTH NAME. IF DIFFERENT
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Christine Marie Avampato
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERE~cozzafava
C. SURNAME AFTER MARRIAGERoddv
(OPTIONAL - SEE REVERS'i!)90-66-0008
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ~Y BPutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY"1J TOWN 0 VILLAGE
~~~CIFYWaP.einger
D. STREET AODRESJ 4 Lor-Mar Court
-.J
11. A. FUll NAME
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSEl.. 30 66-4260
D. SOCIAL SECURITY NUMBER 'I _ -
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY'ItJ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 316 All Anaels Hill Rd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YEd"'b NO
08 /17 /1978
MONTH DAY YEAR
ZIp12590
o YES....O NO
>971
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE?
13. A. AG~8 3B. DATE OF BIRTH 07 ,.99
MONTH DAY
3.. A. AGE~1
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION IT
B. TYPE OF INDUSTRY OR BUSINESS Cartus
5. PLACE OF BIRTH New Rochelle. NY
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Kevin Edward Roddy
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Maureen Anne O'Connell
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
14. EMPLOYMENT
A. USUAL OCCUPATIO~ffice Assistant
B. TYPE OF INDUSTRY OR BUSINESSGovernment
15. PLACE OF BIRT~oughkeepsie, NY
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMERonald Scozzafava
'B. COUNTRY OF BIRTM S A
17. MOTHER
A. MAIDEN NAMEAgnes Elizabeth Nolan
B. COUNTRY OF BIRT~ S A
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) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (g) !J DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 06 / 09 / 20U3
MONTH DAY YEAR MONTtII' 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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 06/09/2003 Poughkeepsie, NY 0 ~
2ND 0 0 2ND D 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH D 0
I duly swear/affirm, aep'ase and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the marnage state . A~I\~
21. SIGNATURE OF GROOM. . SIGNATURE OF BRIDE. ~ W~__
USE USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME 2/03/2009
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 ~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 urpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) John C. Masterson
TIME MONTH YEAR MONTH
SEAL SIGNATURE" DATE
MAILING ADDRESS 09:28AM 12
'-v-I Middleb PM
STREET ZIP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
o
YEAR
04
2009
02
01 2010
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYcf)uT~SS
1~ CIVIL
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF I2t TOWN OF 0 VilLAGE OF
SPECIFY lEA!!>; ht;A/tijl
~
ZIP
31. WITNESS TO CEREMONY k
NAME (PRI~-l. }.JO{ ;..n~
SIGNATURE....;.- 'fI:u~.A/l ~