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CITYrrOWN Wappinger
~~~:~c~ 1368
~~~I~~~R 70
......_. I-U II IV."""" I '-'I I .....T"\~ II I
1, A, FULL NAME
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Christian Jacques Guy' Molenaer
FIRST MIDDLE CURRENT SURNAME
FIRST
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ashley Anne Haan
MIDDLE CURRENT SURNAME
~
11, A, FUll NAME
B, BIRTH NAME, IF DIFFERENT
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE Molenaer
(OPTIONAL - SEE REVERSE.. 05-74-6676
D, SOCIAL SECURITY NUMBER . I
12, RESIDENCE ANY BDutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY 0 TOWN~ VILLAGE
~~~CIFYWappingers Falls
D, STREET ADDRESl97 Old Route 9n; Apt B5
ZIP 12590
....0 YES 0 NO
)986
YEAR
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)056 74 8411
D, SOCIAL SECURITY NUMBER --
2 RESIDENCE A. NY B, Dutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY 0 TOWN'G VILLAGE
~~~CIFY Wappingers Falls
D, STREET ADDRESS 797 Old Route 9n; Apt B5 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
3. A, AGE 23 3B. DATE OF BIRTH 11 / 30 /1985
MONTH DAY YEAR
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13, A, AGE22 3B, DATE OF BIRTH 08 ~1
MONTH DAY
4, EMPLOYMENT
A. USUAL OCCUPATION Gutter Guy
B, TYPE OF INDUSTRY OR BUSINESS Seamless Gutters
5, PLACE OF BIRTH Bronxville, NY
(CITY, STATE / COUNTRY IF NOT USA)
6, FATHER
A. NAME Jean-Jacques Molenaer
B, COUNTRY OF BIRTH France
7, MOTHER
A, MAIDEN NAME Emily Ann Croce
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
o 0
14, EMPLOYMENT
A. USUAL OCCUPATION Teacher Assistant
B, TYPE OF INDUSTRY OR BUSINESS Dutchess BOCES
15. PLACE OF BIRTH Beacon, NY
(CITY, STATE / COUNTRY IF NOT USA)
16, FATHER
A, NAME DouQlas James Haan
'B, COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Patricia Ann Galvin
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
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
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
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
(3) 0 ANNULMENT
/ /
o 0
o 0
o 0
o 0
declare that f)O legal impediment exists
/
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1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swe!lr/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true an
as to my nght to enter Into the marriage state.
/5J?~
21. SIGNATURE OF GROOM~ &:./" ~----
USE CURR
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
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 by New York Domestic
Relations Law ~l1-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 MONTH
SEAL SIGNATURE ~ DATE 07/10/2009
"-- -.J MAI~rw "ODI)FlE~S AM 07 11 2009 09 08 2009
-v- LU IVI 001 ush Rd, Wappingers Falls, NY 12590 03:43PM .
STREET CITYrrOWN STATE ZIP
~~~R~~Ri:~~ ~~O~~~N~~E~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO, DAY YEAR oX RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED, 9 0 OTHER, SPECIFY
22. SIGNATURE OF BRIDE~
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B, COUNTY':h~
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF
SPECIFY
NAME (PRINT)
SIGNATURE'-