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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c: 1 368 .
~5~~J~R 118
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Joel Rvan Petrus
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
Lo
1 . A. FUll NAME
11. A. FUll NAME
SUPPLEMENTAL FILE
FROM THE BRIDE
Patience Elizabeth Gauzza
MIDDLE CURRENT SURNAME
~
FIRST
..
I:J
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 054 68-4528
D. SOCIAL SECURITY NUMBER -
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY PouQhkeepsie
D. STREET ADDRESS 60 Cardinal Dr. ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES '6 NO
3. A. AGE 26 3B. DATE OF BiRTH 06 / 18 / 1983
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Petrus
(OPTIONAL. SEE REVERSE) 1 05-74-2466
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STATE),J, (COUNTY)
C. CHECK ONE .' q CITY LJ. TOWN 0 . VILLAGE
~~~CIFY PoughkeepSie
D. STREET ADDRESS60 Cardinal Or.
ZIP 1ZoU1
DYES '6 NO
)'984
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 25 3B. DATE OF BIRTH 06 ~9
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Deputv Sheriff
B. TYPE OF INDUSTRY OR BUSINESS Police
5. PLACE OF BIRTH Poughkeepsie, NY
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Joel Joseph Petrus
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Katherine D. Schomann
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. ~~~~l?~e'lRMo'1~~AE~T8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Register Nurse
B. TYPE OF INDUSTRY OR BUSINESS Health Care
15. PLACE OF BIRTH PoughkeepSie, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Andrew Eu~ene Gauzza
'B. COUNTRY OF BIRTH U A
17. MOTHER
A. MAIDEN NAME Linda Iris Larson
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1.
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIOORCE CIVIL ANOULMENT
DEATH
o
DEdTH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. - YEAR
B. HOW DID LAST MARRIAGE END?
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/aftinn. aeRose and say, that to the best of m
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM~
o 0 1~ 0 0
o 0 ~D 0 0
o 0 ~D 0 0
o 0 4TH 0 0
owledge and belief that the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ ~ ~ .:.......<:....lL ~ ~ ~ ""..., -:;;fJoo-
USE CURR~ NAMe"
DATE 10/02/2009
W
CJ)
Z
W
(,)
::i
SEC
23. SUBSCRIBED AND SWORN TO/AF RMED 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 pl!rson authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New Yorl< State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl for the urpose of a second or subsequent ceremony.
r-I'-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Jo C. Masterson
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~. DATE 10/02/200
'-v-' MAI~tJi?~a1~ sh Rd, Wappingers Falls, NY 12590 03:38~~ 10 03 2009 12 01 2009
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER- . /'
SONS NAMED ABOVE ON THE YEAR 0 0 RELIGIOUS 1 [![ CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 0\)<) 90 OTHER. SPECIFY
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY LU s kv
TITLE
'(WvY'. J 01 Ce/
1lI,/2ooel
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 1ir10WN OF 0 VILLAGE OF
SPECIFY CsIJPlA..'j
,
DATE
12$~
STATE
ZIP
31. WITNESS TO CEREMONY - A-... ~'c>.J\ A
NAME (PRINT) ~i:. 0 Jv'\.t. \.lQ ~ ~
SIGNATURE~ Afj.,'A (l'~a~
p~