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COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~; 1368
~~~I:~~R 62
~ I A leur I~CVV JUI1~
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Matthew Scott Basztura
MIDDLE CURRENT SURNAME
~
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
1. A. FULL NAME
FROM THE BRIDE
Donna Marie Fasulo
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Whiteway
c. SURNAME AFTER MARRIAGE Basztura
(OPTIONAL. SEE REVERSE016_56_0772
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(STATE),J.., (COUN1Y)
C. CHECK ONE [J CITY L.J TOWN 0 VilLA. GE
~~~CIFY PoughKeepSie
D. STREETADDREss19 Alex Way .
11. A. FULL NAME
FIRST
a.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)041_76_5228
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D STREET ADDRESS 19 Alex Way
12oU;:S
ZIP
"-
o YES 0 NO
;1'965
YEAR
12603
ZIP
YES"6 NO
/1976
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE?
13. A. AGE43 3B. DATE OF BIRTH 08 )t1
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VilLAGE? 0
3. A. AGE 32 3B. DATE OF BIRTH 08 / 1 0
MONTH DAY
MONTH
DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Deportation Officer
B. TYPE OF INDUSTRY OR BUSINESS Government
5. PLACE OF BIRTH Bridgeport, CT
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Rudolf EUQene Basztura
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Cheryl Ann Davis
B. COUNTRY OF BIRTH USA
6. NUMBER OF THIS MARRIAGE 1
14. EMPLOYMENT
A. USUAL OCCUPATION Human Resource Specialist
B. TYPE OFINDU~TRY OR ElUplNESSGoverllment
15. PLACE OF BIRTH~ambnage, MA .
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Edward Coulter Sr.
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Merle E. Whiteway
B. COUNTRY OF BIRTHU S A
2
16. NUMBER OF THIS MARRIAGE
0:'
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI1'ORCE CIVIL A~ULMENT
>I
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVOR6E (3) 0 A~NUlMENT 19(~2 DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 6 /1 /
MONTH DAY YEAR MONTltV DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10, IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (t:10NTH,{lAY, YEAR) (CJTY\COUNTY, SJ/:TE/COUNTRY,JF JI);JT USA) SELF SPOUSE
o 0 1 ST u6/1 u/1992 Miaa esex ~ounty, IVIA 0 ~
o 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
f my knowledge and belief that the information I prOVided IS ~d that I declare that no legal Impediment exists
22 SIGNATURE OF BRIDE. ~~l.A ~ 0 ts:+-
USE R T ME US"t CURRENT NAME 07. /06/2009
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by al'ly'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 C~ERK 25. A, SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Jonn C. Masterson
{SEAL SIGNATURE ~' DATE 07/06/2009 YEAR MONTH
'-v-I MAI~~ltRr88f ush Rd, Wappingers Falls, NY 12590 09 04 2009
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY )t
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR D 0 RELIGIOUS 1 CIVIL
DATE AND AT THE TIME AND AM <:;;
PLACE INDICATED. 001 90 OTHER, SPECIFY
29. OF~~
NAME (PRINT)
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
D1tTH
21. SIGNATURE OF GROOM.
W
en
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W
o
:J
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYW11SfJIN6roJ.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECI~J1. WI C H
NAME (PRINT)
SIGNATURE~
DOH-9B (0312006)
SIGNATURE~