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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~~T 1368
~~~'~:~R 166
::iIAIE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Scott Andrew Massey
MIDDLE CURRENT SURNAME
CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Tiffanie Ann Burke
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
MIDDLE
lL
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Massey
(OPTIONAL - SEE REVERSE)094_60_9949
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STATE).L (COUNTY)
C. CHECK O~i . 0 CITY [J TOWN 0 VILLAGE
~~~CIFY vvapplnger
D. STREET ADDRESsLL Losee Koad
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)118_66_4997
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 22 Losee Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES tJ NO
07 /27 /1975
DAY YEAR
3. A. AGE 33
3B. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 33 3B. DATE OF BIRTH 06 /17
'12::>90
ZIP
o YES~ NO
;rg( 5
YEAR
MONTH
MONTH
DAY
l-
S;
cr:
c
u:
LL
cr:
4. EMPLOYMENT
A. USUAL OCCUPATION Service Tech
B. TYPE OF INDUSTRY OR BUSINESS HV AC
5. PLACE OF BIRTH Newburgh, Ny
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Samuel C. Massey
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Dorothy L. Fravezzi
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
DEeTH
14. EMPLOYMENT
A. USUAL OCCUPATION Analyst
B. TYPE OF INDU~TRY OR BUSI!lI.ESS Hospital
15. PLACE OF BIRTH ~haron, LA
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME David J. Burke
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Betsy L. Richards
B. COUNTRY OF BIRTH USA
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. 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
/ /
- 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
"
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 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter Into the mama state. ~~ ,/J ~ '"
21. SIGNATURE OF GROOM. 22. SIGNATURE OF BRIDE. ~ ~J.~
USE USE CUR~ENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME 10/23/2008
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New 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 C. Masterson
TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ DATE 10/23/200
'- -.J MAI~tiG f.r;;ID~ERSe AM 1 0
--yo- LU IV! am appingers Falls, NY 12590 12:59PM
STREET CITYITOWN STATE ZIP
~~~R~:RT~t~ 'o~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 rh~flELlGIOUS
DATE AND AT THE TIME AND "'f
PLACE INDICATED. ~,,~ PM /0 ;) ~ off 90 OTHER, SPECIFY
~~~ti~~~T /I- D v Ct ( e TITLE /? e c ~ r-
SIGNATURE ~ / / &.L- U DATE / b /2-.r / D I'
MAILING AD DR Sa'?Vl /
/2- Sa ~y/~ e PI tV. / 2.-s-et lJ
STREET ZIP
30. WITNESS TO CEREMONY 31. WITNESS TO CEREMONY
NAME (PRINT) & '(' b
YEAR
24
2008
12
22 2008
2B. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTYJJt.c{.C. 6e ~ \'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF J:\3' VILLAGE OF
SPECIFY Wap";AL.1t:"'S F'o..Us
NAME (PRINT)
.. ----;-
SIGNATURE~
DOH-98 (03/2006)
SIGNATURE~