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1. A. FULL NAME
STATE OF NE.W YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Sal'1at~b~ECharl~i Qjgf~~~NAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
COUNTY [)lltchess
CITYfTOWN '^'8ppinOAr
~~~:kCRT 1368 .
~~~I~l~R 10R
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ijlli::ln RAth Rnm::lnn
MIDDLE CURRENT SURNAME
.J
11. A. FUll NAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SYS~~~M\:~~rl~~I~~~J;?iPressi
D. SOCIAL SECURITY NUMBER 108-76-3600
12. RESIDENCE ANY B. nlltr.hp.!=:!=:
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VilLAGE
AND W .
SPECIFY applnger
o STREET ADDREss46B Scarborough Lane
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 055-7./1-8930
2. RESIDENCE A. N);TATE) B. ~6~eii
c. CHECK ONE 0 CITY,j2J TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 4RR Sr.::lrhnrnllgh I anp. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
MO~ / ~~ / ~79
ZIP 12590
o YES..o NO
A!=lR!i
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE24 3B. DATE OF BIRTH 07 /1'4
MONTH DAY
3. A. AGE 30
4. EMPLOYMENT
A. USUAL OCCUPATION Union Electrician
B. TYPE OF INDUSTRY OR BUSINESS I iOhtino
5. PLACE OF BIRTH North Tar~to\Aln NY
(CITY, STATE I COU RY IF Not USA)
6. FATHER
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUpATION Sp.r.rp.t;:! ry
B. TYPE OF INDUSTRY OR BUSINESS Fire Department
15. PLACE OF BIRTHPouahkeensie, NY
ICITY,~ATE / COOORY IF NOT USA)
16. FATHER
A. NAMEThnm::l!=: I olJi!=: Romano
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Doris Margaret Tibbetts
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
o
A. NAME IOaeph Anthony DiPressi
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME I ynrl(;l ~lloliAlmn
B. COUNTRY OF BIRTH I I S A
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
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
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 ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
ledge and belief that the information I provided is
I
o 0
o 0
o 0
o 0
tha no legal impediment exists
21. SIGNATURE OF GROOM.
23. SUBSCRIBED AND SWORN TO/AFFIRMED B
SIGNATURE OF TOWN OR CITY CLERK~
This license authorizes the marriage in New' Y 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 C Masterson
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE 09/11/2009'
MAILING ADDRESS AM
'-.,-'. Falls NY 12590 03:52PM 09
STREET STATE ZIP
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. /1 ~OO, 9 0 OTHER, SPECIFY
22. SIGNATURE OF BRIDE ~
DATE
by New York Domestic
MONTH
YEAR
11
10 2009
12
2009
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN-rvJlIld~ss
C. LOCATION OF CEREMONY
(CHECK ONE AND yPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECI~S~k; II
NAME (PRINT)
SIGNATURE~