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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Gre~~~ James ~~~~~q~RNAME
COUNTY Dutchess
CITYrrOWN Wappinger
~~~:f: 1368 .
~~~I:J~R 56
1, A. FULL NAME
ll.
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 085 68 6087
D. SOCIAL SECURI1Y NUMBER --
2. RESIDENCE A New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY I!I' TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 114 Smithtown Road; Apt ~IP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 29 3B. DATE OF BiRTH 01 / 11 / 197
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Wapp Cent School Dist
5. PLACE OF BIRTH Carmel, New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Nicholas J. Berardo
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Doris L. Hyden
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEAlt
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) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Heather Erin Backus
MIDDLE CURRENT SURNAME
--1
11. A. FULL NAME
FIRST
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Berardo
(OPTIONAL - SEE REVERSE) 056-74-1867
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY rI TOWN 0 VILLAGE
~~CIFY Wap~inger
D. STREET ADDRESS 114 Smithtown Road; Apt 2 ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
12 /19
DAY
12524
YES ~ NO
/1980
YEAR
13. A. AGE 26
3B. DATE OF BIRTH
MONTH
14. EMPLOYMENT
A.. USUAL OCCUPATION Teacher ,
B. TYPE OF INDUSTRY OR BUSINESS New York State Parks
15. PLACE OF BIRTH Mount Kisco, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Matthew Roger Backus
'B. COUNTRY OF BIRTH U S A
17. MOTHER
A. MAIDEN NAME Nancy Karen Morrissey
B. COUNTRY OF BIRTH U S A
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL ANOLMENT
D~H
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE{S) ALIVE? 0 YES 0 NO
..
20. IF PREVIOUSLY DIVORCED OR ANNtlttf!D, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE 'PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
dge and belief that the information I provided is tru~1d tha~' .declare that no legal impediment exists
22.SIGNATUREOFBRIDE~ 1~ ~
USE CURRENT NAME 06/20/2007
DATE
23. SUBSCRIBED AND SWORN TO/AFFIRMED
SIGNATURE OF TOWN OR CITY CLERK.
This 'license authorizes the marriage in New Yo State of toe 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 C 7f C. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)
TIME MONTH YEAR MONTH
SEAL SIGNATURE.
MAI~1tlA'Cfd~ rf'.M 06 21 2007 08 19 2007
'-v-' 04:4~M
STREET ZIP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
c,.1- ,
::~:'\~\~ L~1 (~)
~--I \cl< >&
STATE
~
NAME (PRINT)
SIGNATURE. '
nOH-Q8 (03120061
1 g..ervIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY\) k. L?c;
C. LOCATION OF CEREMONY
(CHECK O~E ~LECIFY)
o CITY OF X; ~:N OF 0 VILLAGE OF <
SPECIFY ~ C) \J CrH. \-( (;.. (.; t" ' ..,
NAME {PRINT)""
SIGNATURE.