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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c~ 1368 .
~G~~l~R 130
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Christg~~er John ~~~E~T~tRNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jacleen May Sario
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A FUll NAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Broast
(OPTIONAL. SEE REVERSE)045 84 8797
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A.CT B. Litchfield
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY Canaan
D. STREETADDRESS65 Foote Avenue ZIp06018
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? "6 YES 0 NO
~2 )1'977
DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 057 -64-6685
2. RESIDENCE A. CT B. Litchfield
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWNo(] VILLAGE
~~~CIFY Canaan
o STREET ADDRESS 65 Foote Avenue ZIP 06018
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? tJ YES 0 NO
02 /29 /1980
MONTH DAY YEAR
13. A. AGE 30
3B. DATE OF BIRTH
11
MONTH
3. A. AGE ?R
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Active Army
B. TYPE OF INDUSTRY OR BUSINESS Militarv
5. PLACE OF BIRTH Hudson. Ny
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Gregory John Breast
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Cynthia Louise Babieck
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
DEATH
o
....
:>
<(
14. EMPLOYMENT
A. USUAL OCCUPATION Retail ManaQment
B. TYPE OF INDUSTRY OR BUSINESS Retail
15. PLACE OF BIRTH New Milford, Ct
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Joseph Alberto Sario
'B. COUNTRY OF BIRTHPortugal
17. MOTHER
A. MAIDEN NAME Donna Bella Renzi
B. COUNTRY OF BIRTHU 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
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?
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
(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
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to the best of
as to my right to enter into the m~~ge state.
21. SIGNATURE OF GROOM~
US
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 by New York Domestic
RelatiDns 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) Jo C. Masterson
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ . DATE 09/08/2008
'-v-I MAI~~G~fcraT~ sh Rd, appingers Falls, NY 12590 10: 16AM 09 09 2008 03 07 2009
STREET CITYrrOWN STATE ZIP PM
~~:R~~~RT~~J 'O~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR O~RELlGIOUS
DATE AND AT THE TIME AND n
PLACE INDICATED. -, /4 C> 90 OTHER, SPECIFY
m\'-..\c>t.J
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
n ledge and belief that the inf~rmation I provided is tr
o 0
o 0
o 0
o 0
al impediment exists
DATE
09/08/2008
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY Ductc..hesS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
29. OFFICIANT
NAME (PRINT)
~\f\
SPECIFY ll.. \A.? p \ ~ C1 ~ R. ~
\
NAME (PRINT)
LA ; n [2;p;" e.~
r)".. ~ 11, L11,
ZIP
31. WITNESS TO CEREMONY
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