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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:f~ 1368 .
~~~~~~R 124
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Chri~b~@hAr Inhn ct)~[J~URNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.1p.F1~DMarie Cassj~~ENT SURNAME
-1
1. A. FUll NAME
11. A. FUll NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Kp.rr~
(OPTIONAL. SEE REVERSE)056 74 9979
D. SOCIAL SECURITY NUMBER ___- -
12. RESIDENCE A. NY B. Bronx
(STATE) (COUNTY)
C. CHECK ONE otJ CITY 0 TOWN 0 VilLAGE
~~CIFY New York
D. STREET ADDRESS 1638 BOQart Ave ZIP 1 0462
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? otJ YES 0 NO
/1'6 %972
DAY YEAR
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 122 54 1288 '
D. SOCIAL SECURITY NUMBER _ __ - __ - _ ___
2. RESIDENCE A. f\lY B nlltr.hA~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY F1pprnger
D. STREET ADDRESS 39 Carroll Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES ~ NO
3. A. AGE 33 3B. DATE OF BIRTH O~ /?? /1 Q74
MONTH DAY YEAR
3B. DATE OF BIRTH
07
MONTH
13. A. AGE ~5
4. EMPLOYMENT
A. USUAL OCCUPATION M;:!intp.nFlnr.p.
B. TYPE OF INDUSTRY OR BUSINESS Supermarket
5. PLACE OF BIRTH Bronx NY
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Kp.nnp.th.1 Kp.rr~, Sr
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Joan Ann Rondelli
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. ~~~~~~~R~"FR~If'~T8us MARRIAGES WHICH ENDED BY
.DIVOflCC----..CIVIl.ANNULMENT .
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Home Health Aide
B. TYPE OF INDUSTRY OR BUSINESS Health Care
15. PLACE OF BIRTH Bronx. NY
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME James H. Cassidy
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Helen Mclntvre
B. COUNTRY OF BIRTHU S A
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE .... CIVIL ANNULMENT
o 0
DEATH
o
DEATH .
o
(2) 0 DEAJH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,'- YEAR
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) (CITYICOUNTY, STATE/COUNTRY. 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
a;"
W
III
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1ST
2ND
3RD
o
o
o
1ST
2ND
3RD
S
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This licBnse authorizes the marriage in New e bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies in New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the urpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) J n C. Mas e son
{TIME MONTH YEAR MONTH DAY YEAR
SEAL SIGNATURE ~ DATE 09/19/2007
'-v-I MA~~G~fcJm ers Falls, NY 12590 05: 16 ~~ 09 20 2007 11 18 2007
STREET CITYITOWN STATE ZIP
~~~R~~Ri~~~ 10~0~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE MO. DAY YEAR 0 Q"'RELlGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY.J)U rc.he.5S'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF lir'rOWN OF 0 VILLAGE OF
SPECIFY US + t=" Is~ k i I {
TITLE ~c.o n
DATE~J.~ ;)..tJtJ7
1f/4~
STATE ZIP
NAME (PRINT)
SIGNATURE~ .
DOH.9B (0312006)
NAME (PRINT)
SIGNATURE~