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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c;1368
~5~1:~~R24
'IJ. I""l.... "". ........ . "". ,.,
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Nicholas Anthony Potenza
MIDDLE CURRENT SURNAME
(In/~ ':''''!ilJC ~UM .::J fl1 Ie u;:'c V/YLr/
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Karissa Marie Lewis
-.J
1 . A. FULL NAME
11. A. FULL NAME
MIDDLE
CURRENT SURNAME
FIRST
FIRST
11.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Potenza
(OPTIONAL. SEE REVERSE084-68-2253
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(STATE).L (COUNTY)
C. CHECK O,tj,!: 0 CITY U TOWN 0 VILLAGE
~~~ClFyl-'oug n KeepSle
81 timltn Rd.
D. STREET ADDRESS
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE120_64_3781
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. NY B Ulster
(STATE) (COUNTY)
C. CHECK ONE 0 CITY-tJ TOWN 0 VILLAGE
~~~CIFY Highland
D. STREET ADDRESS 258 Milton Cross Rd.
12528
ZIP
.;
Y)9B~O
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES';O NO
05 /11 /1980
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE25 3B. DATE OF BIRTH 11 ,28
MONTH DAY
3. A. AGE28
3B. DATE OF BIRTH
MONTH
~
5>
<(
o
4. EMPLOYMENT
A USUAL OCCUPATION Electrical Contractor
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH PouQhkeepsie, NY
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Lawrence Anthonv Potenza
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Betty Jean Place
B. COUNTRY OF BIRTH USA
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 Nurse
Medical
B. TYPE OF INDl./,SJRY OR ~U..sINESS
15. PLACE OF BIRTHMount I\ISCO, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEM. Bradley Lewis
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A MAIDEN NAME Elizabeth R. Cantone
B. COUNTRY OF BIRTHU S A
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DOORCE CIVIL A~ULMENT
D11TH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
~ YEAR
B. HOW DID LAST MARRIAGE END?
C. DATE LAST MARRIAGE ENDED?
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
~
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
1ST 0 0 1ST
2ND 0 0 2ND
~D 0 0 ~D
4TH 0 0 4TH
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is tr
as to my right to enter into the marnage state
/'
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~
o 0
o 0
o 0
o 0
no legal impediment exists
SE R ENTN
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
RelatiDns Law 911 to periorm 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) Jon .
TIME MONTH YEAR
SEAL SIGNATURE ~ E
MAILING ADDRE~ AM 04
'"-v-' 20 Middl 03:05PM
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE 04/16/2009
by New York Domestic
MONTH
YEAR
06
15 2009
17
2009
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCUR~
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF \2lOvILYlGE OF
SPECIFY LJ.r '-AAtJc..ItVt \..L ~
TITLE Il c.. P ~
!J11./ 09
I 2...r:tlo
ZIP
31. WITNESS TO CEREMONY
c~
NAME (PRINT)