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COUNTY Dutchess
CITYrrOWN Wappinger
~~~~~c~ 1368
~5~I~J~R 76
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Frank Charles Patterson
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Maria Frances Palermo
MIDDLE CURRENT SURNAME
-.J
1 . " FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Patterson
(OPTIONAL. SEE REVERSE)094_68_0239
D. SOCIAL SECURITY NUMBER
12 RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY tJ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS8 Baldwin Dr.
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)056_66_1 024
o SOCIAL SECURITY NUMBER
2 RESIDENCE A NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY '6 TOWN 0 VILLAGE
~~~CIFY Wappinger
o STREET ADDRESS 8 Baldwin Dr. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"6 NO
10 / 13 /1974
DAY YEAR
ZIP 12590
DYES '6 NO
,%981
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 26 38. DATE OF BIRTH 12 ",.50
3. A. AGE 33
38. DATE OF BIRTH
YEAR
MONTH
DAY
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Nyc Schools
15. PLACE OF BIRTH East Meadow, NY
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Edmund F. Palermo
'8. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Diane Gazzo
B. COUNTRY OF BIRTHU S A
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
4. EMPLOYMENT
A. USUAL OCCUPATION Assistant Principal
B. TYPE OF INDUSTRY OR BUSINESS Education
5. PLACE OF BIRTH New Yark, NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Francis P. Patterson
B. COUNTRY OF BIRTH Ireland
7. MOTHER
A. MAIDEN NAME Janet M. Hegarty
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. 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 (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
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
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
w
tJ)
Z
W
o
::i
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 swe!lr/affirm, depose and. say, that to. the best of my knowledge and belief that the information I provided is true.and t.hat I declare that Tlt>(t. . gal im.pediment exists
as to my right to enter Into the ~~:~e st~. () .7'! ":. ~/'..
21, SIGNATURE OF GROOM ~ -7"-..<.fl I~ ~ 22 SIGNATURE OF BRIDE ~ v/t; <</'2...(..;. t:t--. ..{./ ~
USE C NAME USE cu RENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME \ ' 07/01/2008
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New rk State of the bride and groom named above by any person authorized by New York Domestic
Relations Law 911 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 CJ..ERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) JOnn C. Masterson
{SEAL SIGNATURE~" DATE 07/01/2008 YEAR MONTH
'-v-I MA~rerMPcf8f Dush Rd, Wappingers Falls, NY 12590 08 30 2008
STREET STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE rMO RELIGIOUS
DATE AND AT THE TIME AND .. - r
PLACE INDICATED. I ~ 0 ~ 9 0 OTHER, SPECIFY
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY.s-u....~~ll::.
10 CIVIL
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF h!: TOWN OF 0 VILLAGE OF
SPECIFY ':I.~ l. F
M. ....\.l \.U'\
SIGNATURE~
NAME (PRINT)
SIGNATURE~
-