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1 . A. FULL NAME
::) I A I I:: U.- NI::W YUHf\.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Ja~~~E Rvan Kn~gaNT SURNAME
FIRST
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c; 1368
~~~I~~~R 61
*~7ij'8~e8FbY Clerk
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Elaine LiVeli
MIDDLE
11. A. FULL NAME
CURRENT SURNAME
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Knapp
(OPTIONAL - SEE REVERSE060_72_5539
D. SOCIAL SECURITY NUMBER
12 RESIDENCE A.NY BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY"6 TOWN 0 VILLAGE
~~~CIFYBeekman
D. STREET ADDRESp5 Sylvan Lake Road
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)129_72_6531
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY..a TOWN 0 VILLAGE
~~~CIFY Beekman
o STREET ADDRESS 227 Sylvan Lake Road ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"D NO
3. A. AGE28 38. DATE OF 81RTH 07 /24 /1980
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE24 38. DATE OF BIRTH 01 .23
MONTH DAY
ZIP 12033
..t.
o YES 0 NO
)'985
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Automotive
5. PLACE OF BIRTH Poughkeepsie, NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Jonathan Ronald Knapp
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Valentina Milanczuk
8. COUNTRY OF BIRTH Belgium
B. 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
8. TYPE OF INDUSTRY OR BUl/.It:lESSSomers CSD
15. PLACE OF 81RTHCarmel, NY
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Ralph LiVeli
. B. COUNTRY OF 81RTJJ S A
17. MOTHER
A. MAIDEN NAME Dawn Edith D'Amico
B. COUNTRY OF BIRTJJ S A
1
1B. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DOORCE CIVIL A~ULMENT
DtfTH
DEATH
o
8. 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?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
J 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
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
to
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
w
en
z
w
o
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,
o 0 1ST 0 0
o 0 ~D 0 0
o 0 ~D 0 0
o 0 4TH 0 0
at to the best of my knowledge and belief that the Information I provided is true and that 1 declare that nUle al impediment exists
e state;.<:7 AI( /, .
~_. 22. SIGNATURE OF BRIDE~ ( '1. 0 ~ ~ rx { 'P ~
USE USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME 06/30/2009
SIGNATURE OF TOWN OR CITY CLERK" DATE
This license authorizes the marriage in New ork State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perlorm 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 (PRIND John C. Masterson
{SEAL SIGNATURE" ('. I DATE 06/30/2009 TIME MONTH YEAR MONTH
~ MA~~GlO\fcfd~S ush Rd, Wappingers Falls, NY 12590 01 :23 ~~ 07 01 2009 08 29 2009
STREET ClTYfTOWN STATE ZIP
~~~R~~~RT~~~ 10~0~~~N~~E~ 26. SOLEMNIZATION OCCURRED 27 TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 ~IVIL
DATE AND AT THE TIME AND *- X\1III
PLACE INDICATED. z: 30 PM 90 OTHER, SPECIFY
~;
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say,
as to my right to enter into the marr
21. SIGNATURE OF GROOM ~
YEAR
28. PLACE WHERE MARRIAGE OCC~
A. STATE NEW YORK B. COU !. 1'ctl-t3S5
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY !2>cJWf<t=PPSi E..
NAME (PRINT)
"-
SIGNATURE"
STATE OF NEW YORK
DEPARTMENT OF HEALTH
Corning Tower The Governor Nelson A. Rockefeller Empire State Plaza Albany, New York 12237
Richard F. Daines, M.D.
Commissioner
James W. Clyne, Jr.
Executive Deputy Commissioner
October 15, 2009
JOHN C MASTERSON
TOWN CLERK
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS NY 12590
Groom:
Bride:
SFN:
JASON RYAN KNAPP
ELAINE LIVELI
25397-2009M
Dear Town/City Clerk:
Enclosed is a copy of the marriage referred to by the above file in your office.
Correction to the original has been made based on:
D Affidavit
IZl Officiant's Statement
D Signature on original marriage affidavit
D Statement verified by City/Town Clerk
D Other: Supplemental
Please file this amended record along with the supporting documentation.
If you have any questions, please call us at (518) 474-2013.
Sincerely,
Linda Ortiz
New York State Dept. of Health
Vital Records Marriage Corrections Unit
P.O. Box 2602
Albany, NY 12220-2602
Enclosure
STATE OF NEW YORK
COUNTY Dutchess DEPARTMENT OF HEALTH
CITYITOWN Wappinger
~~:~c:1368 AFFIDAVIT, LICENSE and
~5~I:J~R61 CERTIFICATE OF
*: ~rrec.-tdJ b~ CleriC lo/lq/o, c'Io MARRIAGE
FROM THE GROOM
Jason Rvan Knapp
MIDDLE CURRENT SURNAME
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STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
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FULL NAME
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Elaine LiVeli
MIDDLE
.-J
11. A. FULL NAME
CURRENT SURNAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
PTIONAL. SEE REVERSE)129_72_6531
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) (CCUNTY)
C. CHECK ONE 0 CITYotJ TOWN 0 VILLAGE
~~~CIFY Beekman
~STREET DRESS 227 Sylvan Lake Road ZIP 1
E. I ESID NCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"D NO
. . AGE28 3B.DATEOFBIRTH 07 /24 /1980
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Knapp
(OPTIONAL - SEE REVERSE060 72 5539
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A.NY BPutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY "6 TOWN 0 VILLAGE
~~~CIFYBeekman
D. STREET ADDRESp5 Sylvan Lake Koad
ZIP 1 Lb33
o YES....D NO
)985
YEAR
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE24 3B. DATE OF BIRTH 01 ,Z3
MONTH DAY
4. EMPLOYMENT
SSUAL tCUPATION Mechanic
. TY 0 INDUSTRY OR BUSINESS Automotive
. OF IRTH Poughkeepsie, NY
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Jonathan Ronald Knapp
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Valentina Milanczuk
B. COUNTRY OF BIRTH Belgium
8. NUMBER OF THIS MARF,lIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSIN.E~Ssomers CSD
15. PLACE OF B'IRTHCarmel, Ny
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMERalph LiVeli
'B. COUNTRY OF BIRTJJ S A
17. MOTHER
A. MAIDEN NAME Dawn Edith D'Amico
B. COUNTRY OF BIRTJJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DOORCE CIVIL A~ULMENT
D~TH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEAJH
(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) (CITYICOUNTY, 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) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/afflnn, dep.ose and say,
as to my right to enter into the mar
21. SIGNATURE OF GROOM ~
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by New York Domestic
YEAR MONTH
YEAR
TIME
MONTH
AM 07
01 :23 PM
01 2009 08 29 2009
1~IVIL
28. PLACE WHERE MARRIAGE OCCUR~
A. STATE NEW YORK B. couNn.i:IL'1C1ft3S.5
C. LOCATION OF CEREMONY /3 /- 3
(CHECK ONE AND SPECIFY) fC7
o CITY OF ,P( TOWN OF 0 VILLAGE OF
SPECIFY ~JrfH+f<.r=FPSi r=..
SIGNATURE~
DOH-98 (0312006)
NAME (PRINT)
....
SIGNATURE~
J5 3'11- 09/i7
olef'-
Village J ustic C
e ourt
W . 7 Mill Street
appmgers Falls N Y
Phone 845_297_67~;2590
Fax 845-298-6057
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