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1 .. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST IO~RP Cyril M~~~ SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
COUNTY 11\ JichASS
CITYfTOWN Wappinger
~~~:~~ 1 ~nR .
~5~I:J~R 77
~
L D SUPPLEMENTAL FILE
FROM THE BRIDE
r.risU~~E AnnA Mn[u~j~NT SURNAME
11. A. FULL NAME
FIRST
"-
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE M~lt~is
(OPTIONAL - SEE REVERSE)114 64 3402
D. SOCIAL SECURITY NUMBER _ _ _ - __ - --__
12. RESIDENCE A. NAW Y nrk B. I1l1tr.hess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY III TOWN 0 VILLAGE
AND W .
SPECIFY applnQer
D. STREET ADDRESS 1668 Route 9: Unit 6e
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER OO~-7 4-~n5Q
2. RESIDENCE A. f\I~~E)YORK B. ~ess
C. CHECK ONE 0 CITY oIZI TOWN 0 VILLAGE
AND W .
SPECIFY appmgAr
o STREET ADDRESS 1668 Route g. Unit 6E ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 25 3B. DATE OF BIRTH n7 / nA. / 1 QR?
uONi'H DAY YEAR
ZIP 12590
o YES~ NO
1977
YEAR
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE ?Q 3B. DATE OF BIRTH 11 ,,04
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION RAr.r1litAr
B. TYPE OF INDUSTRY OR BUSINESS Staffing
5. PLACE OF BIRTH Haverhill r New Hampshire
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME William Arthllr Maltais
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Catherine Ann Rogers
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A.' USUAL OCCUPATION Receptionist
B. TYPE OF INDUSTRY OR BUSINESS Orthodontist
15. PLACE OF BIRTH Brooklyn. New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Robert A Moccia
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Roseanna F. Tursi
B. COUNTRY OF BIRTH USA
18. 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 DEATH
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
." - YEAR
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
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. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
C. DATE LAST MARRIAGE ENDED?
1ST
2ND
3RD
4TH
I duly swear/affirm, dep'ose and say,
as to my right to enter Into the m
21. SIGNATURE OF GROOM. /
o
o
o
1ST
2ND
3RD
o 0
o 0
o 0
o 0
a thal no legal impediment exists
22. SIGNATURE OF BRIDE.
USEC
23. SUBSCRIBED AND SWORN FFIRMED BEFORE ME
SIGNATURE OF TOWN OR 0 CLERK ~
This license authorizes the marriage in New Y i'k State of th 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 purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) J n C. Mast son
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ .. DATE 07/25/2007
"-.-J MAI~~~~~~ ppinger Falls, NY 12590 AM 07 26 2007 09 23 2007
-v- 01 06:39PM
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER. .v
SONS NAMED ABOVE ON THE TIME M. DAY YEAR 0 ~ RELIGIOUS
DATE AND AT THE TIME AND ~o I
PLACE INDICATED. (p .- PM - 0 - P 9 0 OTHER, SPECIFY
29. OFFICIANT t:;;~~) / ..v/z.. "7:)0 t/e;'~
NAME (PRINT) TITLE A:-t-
SIGNATURE~ rf2 ~ DATE ?.."...'/O -19 7
",u"'f""~ f7a;;:; ;,-~- _~, V'U/I+t.L4
STREET CITYfTOWN STATE
30. WITNESS TO CEREMONY 1Gti..; J 4 0
NAME (PRINT)
07/25/2007
DATE
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B~~tee
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ OF 0 TOWN OF 0 VILLAGE OF
SPECIFY /YP;.A/R~rA.e/k
trr
SIGNATURE~
DOH-98 (0312006)
1/1