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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~CRT 1368 .
~~~~;~R 64
~ . 1"'\ . L. "'. '''L... . ""...,
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Patrick Scott Fisher
MIDDLE CURRENT SURNAME
FIRST
{Inl;:' ':>>"'l1vC" ,un ,;;)111 Ie vue V/VL..I/
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jennifer Linn Pierro
MIDDLE CURRENT SURNAME
-1
1. A. FULL NAME
11. A. FULL NAME
FIRST
"-
N
B. BI RTH NAME, IF 01 FFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEl088_76_1357
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0(] TOWN 0 VILLAGE
~~~CIFY Wappinger
o STREET ADDRESS 407 Chelsea Cay ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'6 NO
3. A. AGE 23 38. DATE OF BIRTH 12 / 13 / 1985
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEl063_70_9755
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY '6 TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDREss407 Chelsea Cay
ZIP 12590
DYES tJ ND
)1'985
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 24 3B. DATE OF BIRTH 03 ~O
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS Automotive
5. PLACE OF BIRTH Mt. Kisco, NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Scott GeorQe Fisher
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Patricia Ann Argyle
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 Graduate Student
B. TYPE OF INDUSTRY OR BUSINESS MSMC
15. PLACE OF BIRTH Port Chester, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME David Michael Pierro
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Dawn Irene DeMarco
B. COUNTRY OF BIRTHU S A
1
1B. NUMBER OF THIS MARRIAGE
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?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(Sl 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 (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
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.ose and say, that t
as to my right to enter into the J!!!l
21. SIGNATURE OF GROOM ~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
dge and belief that the information I provided is rue
o 0
o 0
o 0
o 0
declare that no legal impediment exists
07/06/2009
w
en
z
w
o
::i
USE CUR
23. SUBSCRIBED AND SWORN TO/AFFIR BEFORE ME
SIGNATURE OF TOWN OR CITY CLE K ~
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 ~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
{SEAL SIGNATURE ~ Q 12- (~1J;(;i1lu., J DATE 07/06/2009 TIME MONTH YEAR MONTH
'-,-I MAI~~~Pcr8r~ush Rd, Wappingers Falls, NY 12590 02: 11 ~~ 07 07 2009 09 04 2009
STREET CITYrrOWN STATE ZIP
~~:R~~~RT:~; 6~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~ RELIGIOUS
DATE AND AT THE TIME AND I / AM
PLACE INDICATED. ., P .2 ;; - 09 9 0 OTHER, SPECIFY
29. OFFICIANT La LA 1\ e. b ~re'\Se\\ ~ -n2 ? ""'~ ,,-"'.... \
NAME (PRINT) - c.J::1( TITLE ~ ~ ~ ~ S::!.J d
SIGNATURE~ ~~fLu~_____ DATE I /2-5) bCf
MAILING AD~~ . \ - ,/\ ~ A'- ~ ~ ..
2.. '8' 1'-t/I<DS'SI"K-f nY-e, '0111_1"\ PA
STREET CITYfTOWN Y STATE
30. WITNESS TO EREMONY
'(\Q...
NAME
DATE
YEAR
2B. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY bU1-rh-es~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF j!SJ TOWN OF 0 VILLAGE OF
SPECIFY "Po 1--\ e,~ oD
NAME (PRINT)
31. WITNESS TO C
NAME (PRINT)
SIGNATURE~
DOH-9B (0312006)
SIGNATURE~