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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c:1368
~~~I~~~R 11 0
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
laser Mg~[i5tepher Xir~RNAME
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
r.incj~D~/~A I ::'Ir.r.n~~ENT SURNAME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 077 -68-5440
2. RESIDENCE A. NV B ()r::'lnnp
(STATE) (COU~
C. CHECK ONE 0 CITY.cJ TOWN 0 VILLAGE
AND
SPECIFY NAwhllrgh
D. STREET ADDRESS 165 Latintown Road. Lot 52 ZIP 12550
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES>C! NO
3. A. AGE30 3B. DATE OF BIRTH n1 /06 /1 Q77
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE V::'IPkAI
(OPTIONAL. SEE REVERSEb
D. SOCIAL SECURITY NUMBER 68-66-2281
12, RESIDENCE ANY B.or::'lnnA
(STATE) (COUmY)
C. CHECK ONE 0 CITY otJ TOWN 0 VILLAGE
~~~cIFYNewburgh
D. STREETADDREss165 Latintown Road. Lot 52 z,P12550
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES~ NO
13, A. AGE?~ 3B. DATE OF BIRTH 01 ,63 ;(.Q82
MONTH DAY YEAR
14. EMPLOYMENT
A, USUAL OCCUPATION Maintenance Assistant
B. TYPE OF INDUSTRY OR BUSINEssDEC
15. PLACE OF BIRTHBeacon. New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME~aul Anthony Laccone
'B. COUNTRY OF BIRTt-U S A
4, EMPLOYMENT
A. USUAL OCCUPATION ~llrArvi!=:nr
B. TYPE OF INDUSTRY OR BUSINESS DEe
5. PLACE OF BIRTHOsweao, New York
(CITY, STA'F'E / COUNTRY IF NOT USA)
6. FATHER
A. NAME HAnry Ch::'lrlAs Y;:JAkAI
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Faith MarY Ballard
B, COUNTRY OF BIRTH USA
8, NUMBER OF THIS MARRIAGE 1
9, PREVIOUS MARRIAGES .,
A. NUMBER OF PREVIOUS MARRIAGES WHfCHENDEDBY
DIVORCE CIVIL ANNULMENT
o 0
17. MOTHER
A. MAIDEN NAME Debra Ann Barton
B, COUNTRY OF BIRTt-U S A
18. NUMBER OF THIS M,6.RRIAGE 1
19. PREVIOUS 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? / (
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
0, 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
a:.'
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1ST
2ND
3AD
4TH
I duly swear/affirm. depose and say, t
as to my right to enter into the marr e
21, SIGNATURE OF GROOM~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
f my knowledge and belief that the information I provided is true a
o 0
o 0
o 0
o 0
legal impediment exists
23. SUBSCRIBED AND SWORN TO/AFFIRMED
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 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) J C. Mast rson
{ /'> TIME MONTH YEAR
SEAL SIGNATURE ~ ,--. DATE 09/05/2007
'-v-I M~~1Oft~dF~ sh Rd, appingers Falls, NY 12590 12:54 ~~ 09 06 2007 11
STREET CITYrrOWN STATE ZIP
~~~~~RT~~J IO~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO, DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
DATE
by New YDrk Domestic
MONTH
YEAR
04 2007
CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AN~CIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
~CIFY5'S~mL
NAME (PRINl')
SIGNATURE~
SIGNATURE~