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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Gr~~E Adam M2~~R~J! SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~c; 1368 .
~5~~~R 41
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kimberly JOY Knapp
MIDDLE CURRENT SURNAME
11. A. FULL NAME
0-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 119 68 1873 (OPTIONAL - SEE REVERSE) 111 72 8859
D. SOCIAL SECURITY NUMBER - - D. SOCIAL SECURITY NUMBER --
2. RESIDENCEA. New York B. Dutchess 12. RESIDENCEA. New York B. OranQe
(STATE) (COUNTY) (STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE C. CHECK ONE 0 CITY r!f TOWN 0 VILLAGE
~~CIFY PouQhkeepsie ~~CIFY Newburgh
D. STREET ADDRESS 33D Hudson Harbor Drive ZIP 12601 D. STREET ADDRESS 8 Brookside Avenue ZIP 12550
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
12 / 13 / 1972 13. A. AGE 33 3B. DATE OF BIRTH 07 /28 /1973
MONTH DAY YEAR MONTH DAY YEAR
3. A. AGE 34
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Electrician
B. TYPE OF INDUSTRY OR BUSINESS Residential Construction
5. PLACE OF BIRTH Bronx, New York
(CITY, STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS Grocery
15. PLACE OF BIRTH Newburgh, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME William Roe Knapp
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Judith Ann Yaeple
B. COUNTRY OF BIRTH USA
1B. NUMBER OF THIS MARRIAGE 2
6. FATHER
A. NAME Robert Moldoff
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Maryann Castelli
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
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVfOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) c1DIVORCE (3) 0 ANNULMENT 99~ DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 01 / 20 / 1
D. ARE ANY FORMER SPOUSE(S) ALIV~ YES 0 ~~ YEAR D. ARE ANY FORMER SPOUSE(S) ALIV~NT[fYES DD~~ . -~ YEAR
..
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) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEA':!) (CITYICOUNTY",STATEICOUNTRY, IF NOT USA) SELF SPOUSE
o 1ST 01/20/199~ Lawton, uklahoma c1
o 2ND 0
o ~D 0
o 4TH
'ef that the Information I provided is t
DEATH
o
DEATH
o
23. SUBSCRIBED ANO SWORN TO/AFAR
SIGNATURE OF TOWN OR CITY C
This 'license authorizes the marriage In New ork State of e bride d groom named above by any person authorized by New York Domestic
RelatiDns Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
urpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
o If checked, this license Is to be used only for the
~ 24. TOWN OR CITY C~ERK
} NAME (PRINT) Jonn C. Masterson
{SEAL SIGNATURE ~ .
MAI~~
'-v-'
TIME
MONTH
YEAR MONTH
YEAR
AM 05
06:16pM
24 2007 07 22 2007
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYDu!chesr
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY (J CYf ~ ^3€r
10 CIVIL
TITLE v'Y11'", 5 ~
DATE~' 3 )or
IV, . J J.-faJ'
ST E
.~
NAME (PRINT)
SIGNATURE~