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COUNTYDutchess
CITYrrOWNWappinger
~~~:~ 368 '
~~~~~~9
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~~E'n P~in~RRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
n::lwn M::lrie Moore
MIDDLE CURRENT SURNAME
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
D.-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Pa i no
(OPTIONAL - SEE REVERSe).
D. SOCIAL SECURI1Y NUMBER 119-56-8669
12. RESIDENCE ANY enlltchess
(STATE) (COUNTY)
C. CHECK ONE 0 C/TY1lJ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D, STREET ADDRESS1505 Route 376
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13, A, AGF~R 3B. DATE OF BIRTH 10
MONTH
14. EMPLOYMENT
A.' USUAL OCCUPATIO~aralegal
B. TYPE OF INDUSTRY OR BUSINEssLegal
15. PLACE OF BIRT~arihattan. New York
(CITY, STATE I COUNTRY IF NOT USA)
16, FATHER
A. NAMF..Ioseph Patrick Moore
'B. COUNTRY OF BIRTiU S A
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIALSECURITYNUMBER ~??-R4-~1?6
2. RESIDENCE A. NXSTATE) B. D(~J~s<::
c. CHECK ONE 0 clTYYO TOWN 0 VILLAGE
AND W .
SPECIFY :::Jppmger
D. STREETADDREss1505 Route 376 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YESO'b NO
3. A. AG>41 3B. DATE OF BIRTH Mctl / ~* /1yg,~~
4. EMPLOYMENT
A. USUAL OCCUPATION nriver
B. TYPE OF INDUSTRY OR BUSINESS Bottini Fuel
5. PLACE OF BIRT~mJahkeeosie. New Yark
(CITY, '!!TATE I co1MTRy IF NOT USA)
6. FATHER
A. NAME Vincent A P:::Jino .Jr
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Carol Ann Mary Arena
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARF,lIAGE 2
17. MOTHER
A. MAIDEN NAMECatherine Ann O'Connell
B. COUNTRY OF BIRnlreland
lB. NUMBER OF THIS MARRIAGE 1
ZIP12590
o YE&'"'b NO
:J;970
YEAR
KR
DAY
DEATH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0 0
B. HOW DID LAST MARRIAGE END? (3)~ DIVORCE (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? 03 / 16 / 2006 C. DATE LAST MARRIAGE ENDED? / /
MONJ:IJ. DAY YEAR MONTH DAY. - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
to
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITVICOUNTY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITVICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
1ST 03/16/2006 PouQhkeepsie. New York tJ 0 1ST 0 0
2ND 0 0 2ND 0 0
~ 0 0 ~ 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, deP.OSe and say, that to the bes f my knowledge and belief that the information I proVidedW'snd that I declare that no legal impediment exists
as to my right to enter Into th amag tate.
21. SIGNATURE OF GROOM ~ . 22. SIGNATURE OF BRIDE 0 J d. f)f, rYllJ(JlJ(___ J
USE - USE CURRE~E
23. ~~~~=~DO~~~Ot~ J;~Ab~~ ~ BEFORE ME DATE 07/31/2007
This license authorizes the marriage in New State of he bride and groom named above by any person authorized by New York Domestic
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 n C. Masterson
{TIME MONTH YEAR MONTH
SEAL SIGNATURE~. DATE 07/31/2007
"--.-J M~~"DIIQR!;Se . F II NY 12590 AM 08 01 2007 09 29 2007
-yo- LU IVI om applnger a s, 03:31 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 M. DA YEAR 0 S;;! RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY l:>vt-c~~7
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF J8 TOWN OF 0 VILLAGE OF
29. OFFICIANT
NAME (PRINT)
V:D1
^ D
ZIP
31. WITNESS TOCEREMONY :? .
NAME (PRINT) VI ~k-.r r;(H If/()
SIGNATURE~ I j.'/.M~ j),J~
SIGNATURE ~
MAILING ADORES
SPECIFY
""p^11tlr eer'le
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)