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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:f; 1368 '
~5~~J~R 60
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert James Blair
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
"I
L 0 SUPPLEMENTAL FILE
~
1, A. FULL NAME
FROM THE BRIDE
Christine Ann Defino-Pizzuti
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Rennert
c. SURNAME AFTER MARRIAGE Blair
(OPTIONAL - SEE REVERSE) 125-58-5213
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY i::Y' TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 7 Gabriella Road ZIP 12590
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13, A. AGE 44 3B. DATE OF BIRTH 03 / 15 /1963
MONTH DAY YEAR
11. A. FULL NAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 050 54 6870
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r!" TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 7 Gabriella Road
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
12 / 04 / 195
MONTH DAY YEAR
3. A. AGE 48
3B. DATE OF BiRTH
l-
S;
-~
Q
u:
u.
~
4. EMPLOYMENT
A. USUAL OCCUPATION Telecommunications
B. TYPE OF INDUSTRY OR BUSINESS Verizon
5. PLACEOFBIRTH Yonkers, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME William Chester Blair Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Marion Hricuk
B- COUNTRY OF BIRTH Poland
8. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATION Domestic Engineer
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Mount Vernon, New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A, NAME Richard Edward Rennert
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Barbara Ann Mallon
B. COUNTRY OF BIRTH USA
1 B. NUMBER OF THIS MARRIAG E 3
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT
1 0 0 2 0
B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) 0 ANNULMENT J.2LD DEATH B. HOW DID LAST MARRIAGE END? (3) D~IVORCE (3) 0 ANNULMENT jg) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 14/ 20 / ~u06' C. DATE LAST MARRIAGE ENDED? 07 / 18 / 2u05
MONTH" DAY YEAR MONTH ~ DAY' . - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNUlteD; PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH"DAY, YEAR) . JqITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTHODAY, YEAR.).. (CITYICOUNTY, STATElCQl!NTRY, IF NOT YSA) SELF SPOUSE
1ST 12hO/2006 white Plains,New York 0 ct 1ST 101 5/199b White Plains, New YorK 0 r1
2ND 0 0 2ND U{f1lj/~UUb wnlte PlainS, New YOrK 0 d"
3RD 0 0 3RD 0 0
4TH ' 0 0 4TH 0 0
I duly swear/affinn, depose and say, ttlat to the best of my knowle e and belief that the Infonnation I provided is true impedime~t . s
as to my right to enter into e stat
---:/.
21. SIGNATURE OF GROOM~ 7.A
23. SUBSCRIBED AND SWORN TO/Pi FIRMED BEFO
SIGNATURE OF TOWN OR CITY CLERK" DATE
This license authorizes the marriage in New Yorl< State of th authorized by New Yorl< Domestic
Relations Law ~11 to perfonn marriage ceremonies within New Yorl< S e. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the u
~ 24. TOWN OR CITY ,cLI'RK
} NAME (PRINT) JOn C. Masterson
{SEAL SIGNATURE" DATE 06/22/200
\..- -.J MAI~Omffleb ppinger Falls, NY 12590 ,f-M 06
-yo- 12:0q,M
STREET CITYITOWN STATE ZIP
~~~R~~Ri~~J IO~O~~N:.z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. AY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
DEATH
o
MONTH
YEAR
TIME
MONTH
YEAR
DAY
08
21 2007
23
2007
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. cou~uT't.~
C. LOCATION OF CEREMONY
(CHECK ONE AN~PEC'FY)
o CITY OF ~TOWN OF 0 VILLAGE OF
SPECIFY IVHPJ~Il-
NAME (PRINT)
.
SIGNATURE"
bOH-9B (0312006)
SIGNATURE"