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UI::t-'AHTMENT OF HEALTH
CITYfTOWN Wappinqer
~~~~~CRT 1368 .
~~~~;~R 176
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Scott Andrew Powers
MIDDLE CURRENT SURNAME
FIRST
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Michelle Quattrone
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
ll.
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER 094-72-0775
2. RESIDENCE A. NY B, Dutchess
(STATE) (COUNTY)
C. CHECK ONE olJ CITY 0 TOWN 0 VILLAGE
~~~CIFY Beacon
D. STREET ADDRESS 25 Masters Place ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? !!1 YES 0 NO
3. A. AGE ?~ 3B. DATE OF BIRTH 06 / 07 / 1979
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Powers
(OPTIONAL. SEE REVERSE) 122 74-0773
D. SOCIAL SECURITY NUMBER -
12 RESIDENCE A. NY B. Dutchess
(STATJ) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~CIFY Beacon
D, STREET ADDRESS 25 Masters Place ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? tJ YES 0 NO
13 A. AGE 23 3B. DATE OF BIRTH 03 Al7 A985
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION HVAC Installer
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH Bronx. NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Charle!=: A Powers
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Janet B. Bloom
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 Sectretary
B. TYPE OF INDUSTRY OR BUSINESS Construction
15. PLACE OF BIRTH Mount Kisco, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Frank E. Quattrone
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME June Boniello
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) 1'1 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 04 / 24 / 2008
MONTH DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~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
04/24/2008 Pouqhkeepsie, Ny 0 ~
o 0
o 0
o 0
ntlat no legal impediment exists
DEATH
o
DEATH
o
(3) 0 ANNULMENT
/ /
YEAR
1 ST [] 0 1 ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, depose and sa ath tsttO teh.~est Df my knowledge and belief that the information I provided is tru.e,...a..:..)n..d...'hat I
as to my right to enter into the ma ltPj ~ . .
21, SIGNATURE OF GROOM~ 11- 22. SIGNATURE OF BRIDE~ )
~u ENT NAME .
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME "1/K~CZ:-~ /
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 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) J~n C. Mas~
{ SEAL 'OG",,""~ ~H e.JIt..~ "'" 11/21/200 "M' Mom" "AR MONTI;
MAILING ADDRES~ _ 11 22 2008 01 20 2
'-v-I STR~9 Middle ush Rd. Wapg~~~~rs Falls's~r 1259~p 009
~~:R~~RT:~~ 10~O~~~N~ZE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
DATE
11/21/2008
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~I.I..TC~
I~
:r~