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COUNTY Dutchess
CITYn-OWN Wappinger
~~~:~c: 1368
~5~1:~~R 58
i:J I '"' I I:; vr I~I:; vv ,vnn..
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
KPJltgLER II~~F!II ~~ENT SURNAME
(THIS SPACE FOR STATE USE ONL YI
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Karen Ann Cassaro
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE May
(OPTIONAL - SEE REVERSEb 0
D SOCIAL SECURITY NUMBER 80-68-232
12. RESIDENCE ANY BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~cIFYWaDDinger
D STREET ADDRES&45A Scarborough Lane
ZIP 12590
o YES'tJ NO
;(982
YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 074-72-8686
2 RESIDENCE A. NY B. nlltr.hF!RR
(STATE) (COUNTY)
C. CHECK ONE 0 CITY olJ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D STREET ADDRESS 45A Scarborough Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES-a NO
3. A. AGE 31 38. DATE OF BIRTH O? /?fi /1978
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE26 3B. DATE OF BIRTH 1 0 ~4
MONTH DAY
~
:>
III(
c
4. EMPLOYMENT
A. USUAL OCCUPATION T F!ar.her
B TYPE OF INDUSTRY OR BUSINESS Van Wyck
5. PLACE OF BIRTH ~~~~~~~nJNTRY IF NOT USA)
6. FATHER
A. NAME Charles Patrick May
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Joan Valoria Kissel
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
B. TYPE OF INDUSTRY OR BUSINESS Van Wvck
15. PLACE OF BIRTHQueens. Nv
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEGary Joseph Cassaro
'B. COUNTRY OF BIRTJ.J S A
17. MOTHER
A. MAIDEN NAME Barbara Marie Venuto
B: COUNTRY OF BIRTJ.J 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?
(3) 0 ANNULMENT
/ /
(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) (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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
o 1ST
o 2ND
o 3RD
4TH
at the information I provided is true :and
o 0
o 0
o 0
o 0
at no legal impediment exists
21. SIGNATURE OF GROOM~
USE CURRENT
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license autborizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law 911 to pertorm 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) Joh
{ 06/29/2009 TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ E
'-v-I MAI~OG~fcraf~ in rsFalls NY 12590 12:18;~ 06 30 2009 08 28 2009
STREET CITYITOWN STATE ZIP
~~~R~~Ri~~~ IO~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
PLACE INDICATED. 9 0 OTHER, SPECIFY
,-
29. OFFICIANT
NAME (PRINT)
06/29/2009
DATE
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY 0JvJ,..;.~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF l2!I TOWN OF 0 VILLAGE OF
SPECIFY&-~~ ~'sL. k~\
SIGNATURE~
DOH-98 (03/2006)