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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
r.hric::trwDg~r nnn~lrl c'~R~~i~u~~AME
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swellr/affirm, dep.ose and say, that to the be~ of ~ knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my nght to enter Into the mama e state. ~ "". .
21. SIGNATUREOFGROOM" L I - 22. SIGNATURE OF BRIDE" .
USE USE CURRENT NAM
EME
23. SUBSCRIBED AND SWORN TO/AFFIRMED B
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New State of t e 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 ERKC 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) JO . Masterson
{ SEAL SIGNATURE~' DATE 08/01/2007 TIME MONTH YEAR
L- -.J M~I(jGrOO~F@ ppinger Falls, NY 12590 AM 08 02 2007
-yo- 05:18 PM
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
COUNTY Dutchess
CITYITOWN Wappinger
~~~~:f: 1368
~5~1:~~R 8 0
1. A. FULL NAME
FIRST
a.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) ,
D. SOCIAL SECURITY NUMBER 060-74-6545
2. RESIDENCE A. NY B. nl Jtr.hAC::C::
(STATE) (COUNTY)
C. CHECK ONE 0 CITY >l'J TOWN 0 VILLAGE
~~~CIFY Fishkill
o STREET ADDRESS 1 Mountain View Knolls Dr; ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES oC NO
3. A. AGE~O .... 3B.DATEOFBIRTH07 /13 /1977
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Electrician
B. TYPE OF INDUSTRY OR BUSINESS Electrical
5. PLACE OF BIRTH Yonkers, NY
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Donald Charles Sawicki
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME April Marie Hoffmann
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULlMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3)0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Nir.olp. CI;:!irp.CI mninoh;:!m
MIDDLE C1'ffiRENT SURNAME
11. A. FULL NAME
FIRST
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~~wir.ki
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 129- 7 4-8767
12. RESIDENCE ANY B.Dlltr.hp.ss
(STATE)' (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Fishkill
o STREET ADDRESS 1 Mountain View Knolls Dr;
ZIP 12524
o YES'6 NO
/1'981
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13, A. AGE'26 3B.' DATE OF BIRTH 05' ,,08
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH White Plains, NY
(CITY, STATE / COUNTRY IF NOT USA)
16, FATHER
A. NAME John Robert Cunningham
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Ursula Honiqsberq
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
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.D 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
E
by New York Domestic
MONTH
YEAR
09
30 2007
CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU;&~"j't.~
.
me, -:J;l" ~C~
DATE t~ 2-tJ07
~ N. . L2..59D
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF ~ILLAGE OF
SPECIFY W A-AOt n.6'"-b ~
STREET
30. WITNESS TO CEREMONY
NAME (PRINT). N,', c~
SIGNATURE~ 3",~ L
DOH-98 (0312006)
~~~
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~