122
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, liCENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(rHIS SPACE FOR STA TE USE ONL Y)
COUNTY Dutchess
g:~~g:N Wappinger
~~~~~~R'l368
NUMBER 122
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
1. A. FULL NAME
3i",OMbJ:t,!epn MasQiMuRNAME
11. A FULL NAME
FIRST
HolI~l~ipolo 8oa~NT SURNAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE uasciole
(OPTIONAL - SEE REVERS!!)'
D. SOCIAL SECURITY NUMBER 057 7 <\ all 4 2
12. RESIDENCE A.NY B,g' '~"'1v'!5C
(STATE) ~~
C. CHECK ONE 0 CITY 0 TOWNJt] VILLAGE
AND
SPEclFYWappingers Falls
D STREETADDRESs2~ N. Mesier A\/e, 2nd FI z1P:12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? .,zJ YES 0 NO
QdNTH /{ ~AY -1 Q~
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 070 70 .4 876
2. RESIDENCE A. ~ 1" B. rw IT -1...---
1'1 \STATE) L.(MWN1""'"''
C. CHECK ONE 0 CITY 0 TOWN r:l VILLAGE
AND .,...
SPECIFY WappingcFs Falls
D STREET ADDRESS 29 N. Mooior fwc, 2nd FI. ZIP 12590 ~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
MJ;}& / ~O / ~2
13. A. AGE23
14. EMPLOYMENT
3B. DATE OF BIRTH
3. A. AGE 26
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUALOCCUPATIONTcacher
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTHc;tiW sQ1J~~.n~~~~ie, NY
16. FATHER
A USUAL OCCUPATION Sales Representative
B. TYPE OF INDUSTRY OR BUSINESS =t"obacco
5. PLACE OF BIRTH 0-- - --~R' I\'V
~1~/"eOtJtl\'Rv IF NOT USA)
6. FATHER
l-
S; A NAME Cllarles reter Masciola
<( B. COUNTRY OF BIRTH .u 8 ,^.
7. MOTHER
A. MAIDEN NAME Virginia Loo Rhinobocl<
B. COUNTRY OF BIRTH U 8 t.
8. NUMBER OF THIS MARRIAGE 1
9. A~~~~~&RM~r~If'&T~USMARRIAGESWIiICH ENDED BY
DIVORCE CIVIL ANNULMENT
,A NAMEStophon John Seaman III
B. COUNTRY OF BIRTHlJ S A
17. MOTHER
A. MAIDEN NAME Ellen Kay Schreiner
B. COUNTRY OF BIRTHlj S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
o
o
(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
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
o 0
o 0
o 0
o 0
impediment exists
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1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ : 0 0 ~
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is tru
as to my right to enter into the m 5nage state.
21. SIGNATURE OF GROOM ~ ./ ; ~
23. SUBSCRIBED AND SWORN/AFFIRMED BEFO: .......!LSE 9fJR_H~rrr ~A~
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
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 tD be used only for the purpose of a second Dr subsequent ceremDny.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
MONTH
YEAR
09/02/2008
YEAR
MONTH
NAME (PRINT)
TIME
09/02/2008 AM
08:55
PM
28. PLACE WHERE MARRIAGE OCCUR~
A. STATE NEW YORK B. COUNTY.J2/..t"*)u
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~
{ SEAL }
'-v-I
+
-
DATE
03
2008
11
01 2008
09
IP
'SA
27. TYPE OF CEREMONY
o 0 RELIGIOUS
oV 9 0 OTHER, SPECIFY
~IL
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
SPECIFY
S Eel CITYrTOWN
30. WITNESS TO CEREMONY
NAME (PRINT) (Y)~'ht.\,t :>. > Cc.:tw\Ci\
SIGNATURE~ ("{'vrMJ..~ ~
n()'-l~QR rn~I?Mh\
STATE ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) :Ra~~ oj .5 ~a"o/" V\
...:: SIGNATURE~~~~-~