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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~c;1368
~0~1~;~R 1 04
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
F J~R k M orri ~nJJRRENT SURNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
I i~H MHrip. Pp.rrotta
MIDDLE CURRENT SURNAME
--1
1. ,A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0..
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Mnrri~nn
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 079-68-5389
12. RESIDENCE ANY Bnlltr.hp.ss
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W '
SPECIFY applnger
D. STREET ADDREss159 Diddell Road
ZIP 12590
o YESo{] NO
;1'983
YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 1 O?-74-1 ?74
2. RESIDENCE A. NY B. [)lltr.hp~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITYolJ TOWN 0 VILLAGE
AND W .
SPECIFY arrmgp.r
o STREET ADDRESS 159 Diddell Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..Q NO
OR /?R /1q7q
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE?4 3B. DATE OF BIRTH 02 .-5'4
MONTH DAY
3. A. AGE28
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Flpdrir.i:m
B. TYPE OF INDUSTRY OR BUSINESS Electrician
5. PLACE OF BIRTHCarmel, New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Frank W Morrison
B. COUNTRY OF BIRTH U S A
7. MOTHER
A. MAIDEN NAME Anna M. Warthol
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
14. EMPLOYMENT
A. USUAL OCCUPATIONAccounts Payable
B. TYPE OF INDUSTRY OR BUSINESS Finance
15. PLACE OF BIRTH8ever!y. MA
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard Perrotta
'B. COUNTRY OF BIRTJ.J S A
17. MOTHER
A. MAIDEN NAME Mary Catherine O'Louqhlin
B. COUNTRY OF BIRTJ.J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A.NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
9. PREVIOUS MARRIAGES
A.NUMBEWOF "PREVIOOS'MARRtAGESVVHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
o
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
1 D. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
o
o
o
1ST
2ND
3RD
o
o
o
21. SIGNATURE OF GROOM~
22. SIGNATURE OF BRIDE~
USE CUR NT N
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York ate of the Ide 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. Maste son
{ ~ ~ ~
SEAL SIGNATURE ~
I.- -J M~1J>I1Oflgrc~~eS AM 08 30 2007
--v- U a 06:37 PM
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER,
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME
PLACE INDICATED.
DATE
08/29/2007
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
10
28 2007
1~
28. PLACE WHERE MARRIAGE OCQURRED
A. STATE NEW YORK B.COU~....it~
C. LOCATION OF CEREMONY
(CHEC E AND SPECIFY)
ITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY t=6 t.L! ""'1C~t"Pt , cr.
D -
NAME (PRINT)
SIGNATURE~
SIGNATURE~