122
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~H 0 0 4TH
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided Is true and
as to my right to enter Into the ma estate. .
21. SIGNATURE OF GROOM~
. u
23. SUBSCRIBED AND SWORN TO/AFFIRMED 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) John . Masterson
TIME YEAR
SEAL SIGNATURE ~ . 10/28/2009
'-v-' MAI~~G~fcraY~ Y 12590 08:37AM 10
STREET STA ZIP PM
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFADAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Edward Grant Adam. JR.
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~c~1368 .
~5~I:J~R 122
1. A. FULL NAME
FIRST
I
STATE FILE NUMBER
(rH/S SPACE FOR STA TE USE ONL Y)
I
0..
'"
B. BIRTH NAME, IF DIFFERENT
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Karen Marie Stenson
MIDDLE CURRENT SURNAME
~
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)132 58 7589
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 ClTYoCl TOWN 0 VILLAGE
~~~CIFY WappinQer
D. STREET ADDRESS 432 All Angels Hill Rd ZIp 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"'D NO
03 /04 /1975
MONTH DAY Y~R
3. A. AGE 34
3B. DATE OF BIRTH
11. A. FULL NAME
FIRST
4. EMPLOYMENT
A. USUAL OCCUPATION HV AC
B. TYPE OF INDUSTRY OR BUSINESS Valco Energy Systems
5. PLACE OF BIRTH Carmel. NY
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Edward Grant Adam
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary Ann Tompkins
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. ~~~~l?~?.rtr~IrE~8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. 'HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. OATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C: SURNAME AFTER MARRIAGE Adam
(OPTIONAL - SEE REVERSEb87 -68-9015
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A.NY BPutchess
(STATE) J-. (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
AND W .
SPECIFY apQlnger
D. STREET ADDRESS432 All Angels HIli Rd
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE38 3B. DATE OF BIRTH 05 ,29
Zlp12o::S3
o YES.....O NO
)971
Y~R
MONTH
DAY
14. EMPLOYMENT
A. USUAL OCCU~ATIONMIS Supervisor
B. TYPE OF INDUSTRY OR BUSINESS ODMDLLP
15. PLACE OF BIRTHBronx, NY
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard Stenson
'B. COUNTRY OF BIRTJJ S A
17. MOTHER
A. MAIDEN NAME Diana Theresa Sugrue
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
D~TH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
".~ Y~R
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
at I declare that no legal Impediment exists
TITLE
DATE
by New York Domestic
MONTH
YEAR
29
2009
12
27 2009
1 Ia"'CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
\)~'r(n ~~ ~.(~
o VILLAG~
wer
SPECI
ZIP
31. WITNESS TO CEREMONY
NAME(PRINT) ~~ I< JFzz~DN
SIGNATURE~ av. ~