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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST CnIAna~~E We!=:lpy \{M~~r?r~MNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~: 1368 .
~5~I:J~R 105
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
T~nekrul~~LEMnniqlJe ~~QfT1.MRNAME
11. A FULL NAME
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL . SEE REVERSE)
D SOCIAL SECURITY NUMBER 152-58-6791
2. RESIDENCE A. NY B. n'ltr.hA!=:~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN olZI VILLAGE
~~~CIFY W~ppingers F~lIs
D STREET ADDRESS 2694 Apt 2 West Main St ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 1!1 YES 0 NO
3. A AGE 35 38. DATE OF BIRTH n7 / nQ / 1 Q74
MOi:li'H DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE W~II~r.F!
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 086-50-0077
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN lZl VILLAGE
~~~CIFY Wappingers Falls
D STREET ADDREss2594 Apt 2 West Main St ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A. AGE ~? 3B. DATE OF BIRTH 04 A:l3 /1'977
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Information T echnplogy
B. TYPE OF INDUSTRY OR BUSINESS Information Technoloqv
15. PLACE OF BIRTH Poughkeepsie. NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Alfred Harvey, Jr
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Geraldine Bronson
B. COUNTRY OF BIRTH USA
16. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
4. EMPLOYMENT
A USUAL OCCUPATION T F!1F!rhnne T F!r.h
B. TYPE OF INDUSTRY OR BUSINESS Telecommllnication
5. PLACE OF BIRTH ~~, s';1~I)~ou~~~ IF NOT USA)
6. FATHER
A. NAME I ~rkA Sllher .Ir
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Norma J Wallace
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
DEATH
o
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(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
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
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
knowledge and belief that the Information I provided is true
o
o
o
1ST
2ND
3RD
4TH
I duly swear/affinn, dep.ose and S
as to my right to enter into the
21. SIGNATURE OF GROOM ~
.?
,.
USE
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 by New York Domestic
Relations Law !l11 to perfonn 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) Jo . Masterson
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~. DATE 09/09/2009
MAILING ADDRESS 09 12AM
'-v-' 20 Middleb sh Rd, Wappinqers Falls, NY 12590 : 09 10 2009 11 08 2009
STREET CITYITOWN STATE ZIP PM
~~~R~~RT~~J IO~O~~~N~ZEE~ 26, SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR o'/i;j( RELIGIOUS
DATE AND AT THE TIME AND AM r
PLACE INDICATED, If; () ,,' PM f t6 0 1 9 0 OTHER. SPECIFY
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B, COUN~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
SPECIFYf{9_f1f~
29, OFFICIANT
NAME (PRINT)
TITLE
(fw..!;v
/ I ,
:5, /~/01
, , I
I DATE
V.
Nit
\MvV"\ ~
s~
SIGNATURE~
NAME (PRINT)
SIGNATURE ~