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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
P::l111 ~8C[::lrd BIIC1f\J~~E~VSURNAME
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, depose and say, thajJ.o the best of my knowledge and belief that the Information I provided is true
as to my right to enter into the m~'$t~
21 SIGNATURE OF GROOM ~. ~ r~ _ .e-- 22 SIGNATURE OF BRIDE ~
,"" us
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New ork Slate of the bride and groom named above by any person authorized
Relations Law 911 to perform marriage ceremonies within New York Slale, 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) n C. Masterson
COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~RT 1368
~~~I~~~R 108
1 . A. FULL NAME
FIRST
Q.
N
8 BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 121-74- 7 493
2. RESIDENCE A. NY B [)lltchess
(STATE) (COUNTY)
C. CHECK ONE olJ CITY 0 TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
D STREET ADDRESS 7 Oak Crescent ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? ~ YES 0 NO
3. A. AGE 24 3B DATE OF BIRTH 11 / O&::. / 1983
MONTH DA;yo' YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Firp.fightp.r
8. TYPE OF INDUSTRY OR BUSINESS Public Safety
5. PLACE OF BIRTH Pouahkeensie, Nv
(CITY, ~ATE / COUNTRY IF NOT OSA)
6. FATHER
A, NAME P::l111 ~p.r::lrrl RI H~hp.r Sr
,
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Jaye Anne Ward
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9 ~R~~~~{RM6'r~IfE<tT6us MARRIAGES WHICH ENDED BY
DIVORCE - 'CIVIL'ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
8. 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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
w
rn
z
w
o
:i
~
{ SEAL }
"-v-I
SIGNATURE ~
MAILING ADDRESS,
20 Middl
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
I:( A \I I t'
ar~Df:II:l1n c en ~bt9ENT SURNAME
.-J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Rllcher
(OPTIONAL - SEE REVERS-m-
D SOCIAL SECURITY NUMBER 081-72-654:1
12. RESIDENCE A. "'~STATE) B. [l1~Y6~~SS
C. CHECK ONE 0 CITY eI TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D STREET ADDRESS 14 Gold Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
13, A. AGE 22 38. DATE OF BIRTH j j a? 4QRJ:;
MONTH nAY VEAF1
14. EMPLOYMENT
A. USUAL OCCUPATION A!=;~i~t::lnt Offir.p. M::ln::lop.r
B. TYPE OF INDUSTRY OR BUSINESS Landscaping
15. PLACE OF BIRTH Pouahkeensie Nv
(CITY. ~ATE / COUNTRY IF NOT DSA)
16. FATHER
A. NAME Mir.h::lp.1 ~p.r::lrrl V::llp.ntinn
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Brenda Marie Danieli
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 (3) 0 ANNULMENT (2) 0 DEATH
C, DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
0, 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
by New York Domestic
TIME
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
MONTH
YEAR
AM
03:47 PM 08
2008
10
16
14 2008
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY));c.JJ$ S S
eo. ,It,sJr
.9
/'2."1il
ZIP
WITNESS TO CERE ON
C. LOCATION OF CEREMONY
(CHECK ONE AN':)PECIFY)
o CITY OF !V"TOWN OF 0 VILLAGE OF
SPECIFY~1IS IE'
NAME (PRINT)
SIGNATURE~