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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
,\, \l)\\r-n MARRIAGE
FROM THE GROOM
FIRST 68njal1lhll.R.uii811 ~~~E
I"
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
D~ M~rie BI~l~ENT SURNAME
FULL NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl. . SEE REVERSE)
D. SOCIAL SECURITY NUMBER 117 -6?-R64Q
2. RESIDENCE A. N (XATE) B. Q~elili
c. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~CIFY W~prina~r~ F~II~
D. STREET ADDRESS ::\ Mc C~ff~rty PI~ce Apt A ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CllY OR INCORPORATED VILlAGE? rJi YES 0 NO
3. A. AGE 30 3B. DATE OF BIRTH MO~ / ~ / y1j77
4. ENPLOYMENT
A. USUAL OCCUPATION Chef
B_ TYPE OF INDUSTRY OR BUSINESS Flik Int~rn~tinn~1
5. PLACE OF BIRTH Vil!"'n~ Of r.nlrl ~nri~!"! !\]pw Y"rk
(CITY. sffiE / COUNTRY IF NOT lISA) ....
6. FATHER
A_ NAME Hector Rodrigl lE'Z
B_ COUNTRY OF BIRTH Pllertn Ricn
7. MOTHER
A_ MAIDEN NAME I IIcille Irel~nn
B_ COUNTRY OF BIRTH I J ~ A
8. NtJMBER OF THIS MARRIAGE 1
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c. slfS~~~r~~~~~~~~s~odriquez
D. SOCIAL SECURITY NUMBER 1 ?4-58-5344
12. RESIDENCE A. N v B. Dllt~he~s
(fi' ATE) (~OUNTY)
C. CHECK ONE 0 CITY 0 TOWN Iii!' VILLAGE
~~CIFY W~ppinger~ Fall~
D. STREET ADDRESS 3 Mc Cafferty Place Apt. A ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CllY OR INCORPORATED VILLAGE? t\ YES 0 NO
13. A. AGE 31 3B. DATE OF BIRTH OR /?4 A Q76
MO~TH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION ~h Inent
B. TYPE OF INDUSTRY OR BUSINESS DC. C
15. PLACE OF BIRTH Bronx, New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Rich~rn RI~II
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Dominica Donna Lospoto
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
9. PflEVIOUS MARRIAGES
A_ NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? L /
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) (CITYICOUNTY, STATEICOUNTRY,IF NOT USA) SELF SPOUSE
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) (CITYICOUNTY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm. dep,ose and say, that to the best of my knowledge and belief that the information I provid
as to my right to enter Into the mamage state.
21. SIGNATURE OF GROOM~ 22. SIGNA RE OF BRIDE~
SEC R
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of th
Relations Law ~11 to perform marriage ceremonies within New York St
o If checked, this license is to be used on
r-"-. 24. TOWN OR CITY CLERK
} NAME (PRINT) John C. Masterson
{SEAL SIGNATURE ~ ~Yv\ c... rro~ DATE 1 0/09/200
"-v-' MAI2N8~~a'al~bush Rd. WappinQers Falls. NY 12590
STREET CllYlTOWN STATE ZIP
~~~~~R~~~ ~~O~~N~1f~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIM DAY YEAR 0 ~ELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICA~~:_) ..'$ PM I 1(, 90 OTHER, SPECIFY
~~'mi '!:b/VfI<:' tI. oftl/2.'( mcEt>/lHIii.-
SIGNATURE ~ d~' t It 1'.1 (' .1i1 T
MAILING ADtJRE S ~ .
- '/,4; "Art- 'n-, >K-
STREET CITYfTOWN
3D. WITNESS T
DATE 10/09/2007
by New York Domestic
bride and groom named above by any person authorized
. THIS LICENSE VALID IN NEW YORK STATE ONLY.
for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
YEAR
MONTH
YEAR
TIME
MONTH
11 :44AM
PM
10
10
2007
12
08 2007
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 0",'jttHC rj.l
C. LOCATION OF CEREMONY I "2{)/
(CHECK ONE AND SPECIFY) /"'::';i
~TY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY
pyc.1'I t!..- Y'
ZIP
31. WITNESS TO CEREMONY
NAME (PRIN1'}-.:::zt~(2 TO i'V
SIGNATURE~' ----
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST B8njsl11mJ~.b1lSlSell R6i1~~E
COUNTY nlltr.hp.!::!::
CITYrrOWN W;:Jppingp.r
~~~~ 1 ~RR .
~5~~~~R 1 ~4
t. A. FUll NAME
0-
N
B. BIRTH NAME. IF DIFFERENT
+
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 117 -R?-RR49
2. RESIDENCE A. N X B. Q~ess
( ATE) )
C. CHECK ONE 0 CITY 0 TOWN ljil VILLAGE
~~~CIFY W;:Jppi"aers Fell!::
D. STREET ADDRESS ~ Mr. r.;:JffArty PI;:JCA Apt A ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIULAGE? r5i! YES 0 NO
MO~ / ~ /y~77
3. A. AGE 30
4. EMPLOYMENT
A. USUAL OCCUPATION Chef
B. TYPE OF INDUSTRY OR BUSINESS Flik I ntp.rn;:Jtinn;:J1
5. PLACE OF BIRTH ~~~~,~~~~l~o~ing. NAW York
6. FATHER
3B. DATE OF BIRTH
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A. NAME Hector Rodrig'lez
B. COUNTRY OF BIRTH PIlArtn Rir.n
7. MOTHER
A. MAIDEN NAME I flr.illA IrAI;:Jnn
B. COUNTRY OF BIRTH I J ~ A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE...~...... . ......._..~.......CI\lIL.ANNuLMEI\II~.~~..
o 0
...DE:ATH
o
(2) 0 DEATH
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) (CITYICDUNTY, STATEICOUNTRY. IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
D I\A' RI
~ w~erlE' -l;lil~lENT SURNAME
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Rodriquez
(OPTIONAL. SEE REVERSE) 1'4 5a 5344
D. SOCIAL SECURITY NUMBER _ __ - _!:!- ____
12. RESIDENCE A. N V B. nlltr.hp.!::!::
mATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN iiil' VILLAGE
~~~CIFY W;:JppingArs Falls
D. STREET ADDRESS 3 Mc Cafferty Place Apt. A ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIULAGE? tl YES 0 NO
13. A. AGE: 31 3B.DATEOFBIRTH OR ""4 /1'97R
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION ~h ,nAnt
B. TYPE: OF INDUSTRY OR BUSINESS DC. C
15. PLACE OF BIRTH Bronx, NAW York
16. FATHER (CITY. STATE I COUNTRY IF NOT U~A)
A. NAME Rir.h;:Jrrl RI;:JII
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Dominica Donna Lospoto
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE: 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH E:NDED BY
QIVORCE CIVIL ANNULME:NT
o 0
DE:ATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE: LAST MARRIAGE E:NDED?
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) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provide
as to my right to enter into the mamage state.
21. SIGNATURE OF GROOM~ 22. SIGNA RE OF BRIDE~
DATE 1 0/09/200
ails. NY 12590
STATE ZIP
27. TYPE OF CEREMONY
o ~ELlGIOUS
9 0 OTHER, SPECIFY
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by New York Domestic
TIME
MONTH
YE:AR MONTH
YEAR
11 :44AM
PM
10 10 2007 12 08 2007
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRE:D
A. STATE NEW YORK B. COUNTY ""0a1ltHCS''/
C. LOCATION OF CE:REMONY
(CHECK ONE AND SPECIFY)
~TY OF 0 TOWN OF 0 VILLAGE OF
Zc.1'f ~~Y'
'j:>1f5 n /Z-
SPECIFY
ZIP
31. WITNESS TO CEREMONY
NAME(PRI~~ORTO 1'V
SIGNATURE:~. --- _
_~IISTATE OF NEW YORK
_W DEPARTMENT OF HEALTH
Corning Tower
The Governor Nelson A. Rockefeller Empire State Plaza
July 18, 2008
John C. Masterson
Town Clerk
Town of Wappinger
20 Middlebush Rd
Wappinger Falls, NY 12590
Groom:
Bride:
SFN:
Benjamin Rodriguez
Donna Blau
57544-07M
Dear Town/City Clerk:
Enclosed is a copy ofthe marriage referred to by the above file in your office.
Correction to the original has been made based on:
D Affidavit
D Officiant's Statement
D Signature on original marriage affidavit
D Statement verified by City/Town Clerk
[gI Other: Supplemental
Please fil~ended record along with the supporting documentation.
If you have any questions, please call us at (518) 474-2013.
Sincerely,
Linda Ortiz
New York State Dept. of Health
Vital Records Section
Marriage Corrections Unit
P.O. Box 2602
Albany, NY 12220-2602
Enclosure
Albany, New York 12237
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TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
CHRISTOPHER J. COLSEY
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
WILLIAM H. BEALE
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
June 23rd, 2008
NYS Department of Health
Peter M. Carucci, Director - Vital Statistics
Corning Tower
Empire State Plaza
Albany, New York 12237
Dear Mr. Carucci
Please fmd enclosed DOH-143 -Supplemental Report for Certificate of Marriage for
Benjamin R. Rodriquez and Donna M. Blau. As indicated on the form, I have
signed my name as Registrar of Vital Statistics.
Please contact me at my office, (845) 297-5771, if there are any problems.
Sincerely,
ohn C. asterson
Town ClerklRegistrar of Vital Statistics
Town of Wappinger
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GROOM BENJAM rrttroMr~tL REPORT FOR CERTIFICATE OF MARRIAGE
RE: BR I DE DONNA M BLAU ITEMS QUERIED
CERT NUM 057544 LOCAL REG NUM 00134
PLACE LIC. ISSUED 1368
ENTRY DATE 11/16/2007 SIGNATURE MISSING IN ITEM 24
DATE PREPARED 02/15/2008
FIRST QUERY
NOTICE MAILED TO:
JOHN C. MASTERSON
TOWN CLERK
TOWN OF WAPPINGER
20 MIDDLEBUSH ROAD
WAPPINGER FALLS
NY 12590
TOWN OR CITY CLERK: PLEASE SEE INSTRUCTIONS ON REVERSE SIDE
I,. A. FuLL NAMe
FROM THE GROOM
FROM THE BRIDE
11. A. FULL NAME
MIDDLE
ClJlRENT SURNAME
CURRENT SURNAME
ARST
0..
N
MIDDLE
AAST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
C. SURNAME AFTER MARRIAGE
2. RESIDENCE A.
B.
12. RESIDENCE A.
B.
(STATE)
ICOIMY)
(STATE )
(COIMY)
C.
C.
IlDCAlllY)
(ZIP CODE)
IlDCAlIlY)
(ZIP CODE)
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3. A. AGE
(STREET ADDRESS)
3B. DATE OF BIRTH
13. A. AGE
(STREET ADDRESS)
13B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION
B. TYPE OF INDUSTRY OR BUSINESS
14. EM~LOYMENT
A. USUAL OCCUPATION
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH
15. PLACE OF BIRTH
(CllY, STATE \ COlMRY IF NOT USA)
ICIlY. STATE \ COUNJRY IF NOT USA)
t:: 6. A. FATHER'S NAME
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16. A. FATHER'S NAME
B. COUNTRY OF BIRTH
17. A. MOTHER'S MAIDEN NAME
B. COUNTRY OF BIRTH
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER Of fHEVIOUS MARRIAGES WHICH ENDED BY
B. COUNTRY OF BIRTH
7. A. MOTHER'S MAIDEN NAME
B. COUNTRY OF BIRTH
8. NUMBER OF THIS MARRIAGE
Q. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS ~MRRIAGES WHICH ENDED 8Y
DIVORCE
CIVIL ANNULMENT
DEATH
DIVORCE
CIVIL ANNUUMENT
DEATH
B. HOW DID LAST MARRIAGE END?
C. DATE LAST MARRIAGE ENDED?
D. ARE ANY FORMER SPOUSE(S) AUVE?
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
IlA TE Of DECREE PLACE ISSUED AGAINST WHOM
{llfONlII, DAY, lIWlI (CITY, STA 1C/C(J(MTAY IF NOT USA) SELF OR SPOUSE
B. HOW DID LAST MARRIAGE END?
C. DATE LAST MARRIAGE ENDED?
D. ARE ANY FORMER SPOUSE(S) AUVE?
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
IlATEOfDECREE PlACE ISSUED AGAINST WHOM
(llfONlII, DAY, ~R) (CITY, STATEJCXilI/TRY, IFNOTUSA) SElFOR SPOUSE
1ST
1ST
2ND
2ND
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3RD
4TH
4TH
I, being duly sworn, depose and say, that to the best of my knowledge and belief thatlhe information I provided is Irue and that I declare that no legal impediment exists as 10 my righl to enter into the marriage state.
22. SIGNATURE OF BRIDE ~
21. SIGNATURE OF GROOM ~
USE ClJlRENT NAME
USE ClJlRENT NAME
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York Slate 01 the bride and groom named above by any person aulhorized by New Yolk Domestic Relations law ~11 to perfOfm marriage ceremonies wilhin New York
Slate. THIS UCENSE VAUD IN NEW YORK STATE ONLY. '
25. A. SOLEMNIZATION PERIOD BEGINS
25. B. SOLEMNIZATION PERiOD
ENDS AT MIDNIGHT ON
DATE
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0 SEAL SIGNA TURE ~
::J
MAIUNG ADDRESS
---..-
STREET
DATE
TIME
DATE
STATE
ZIP
C1lYnowN
ll..t:.li Ill'" Y 1 HA I I :::iULt:MN\Lt:.U ~O. ::iULt:.MNILA IIUN UL;L;UlilitU <.I. I Y~t Ur l;tHtMUNY 28. PLACE WHERE MARRIAGE OCCURRED
THE MARRIAGE OF THE PER- A. STATE NEW YORK B. COUNTY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 10 CIVIL
DATE AND AT THE TIME AND o 0 REUGIOUS C. LOCATION OF CERMONY
AM
~ PLACE INDICATED. PM g 0 OTHER, SPECIFY (Chedc one and speCIfy)
29. OFFICIANT o CITY OF o TOWN OF o VILLAGE OF
0 NAME (Print)
u: TITLE
1= SPECIFY
CC SIGNATURE ~ DATE
\IJ
0 MAIUNG ADDRESS
STREET C1lYnowN STATE ZIP
30. WITNESS TO CEREMONY 31. WITNESS TO CEREMONY
NAME (PrIMt) NAME (PrIMt)
SIGNA TURE ~ . SIGNA TURE ~
AFFIRMATION: I affirm under the penalties of perjury thaI the information given TO BE COMPLETED BY THE REGISTRAR OF VITAL STATISTICS:
in the facsimile of the record of marriage for the couple identified The above information has been added to the local record of marriage on file in
above is true and correct information to be added to the original
certificate of marriage and the local town/city clerk's record, this office.
Signature:
Title or Relationship to Couple
Date
T own/Citv Clerk
nil!"