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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~cRT 1368 .
~~~~J~R 28
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Adam David Melish
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Melissa Ann Cioffiro
MIDDLE CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
11.
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Cioffiro-Melish
(OPTIONAL - SEE REVERSE) 068 70 9789
D. SOCIAL SECURITY NUMBER --
12. RESIDENCEA. New York B Dutchess
(STA~) (COUNTY)
C. CHECK ONE I!I CITY 0 TOWN 0 VILLAGE
~~CIFY PouQhkeepsie
D. STREET ADDRESS 68 Cedar Avenue ZIP 12603
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? rJ YES 0 NO
03 /23 /1980
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1 5 8 03 4
D. SOCIAL SECURITY NUMBER 4 - 0- 9
2 RESIDENCEA. New York B. Dutchess
(STATF) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 68 Cedar Avenue ZIP 12603
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? C'f YES 0 NO
01 / 03 / 1980
MONTH DAY YEAR
3. A. AGE 27
13. A. AGE 27
3B. DATE OF BIRTH
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Electrician
B. TYPE OF INDUSTRY OR BUSINESS Electrical
5. PLACE OF BIRTH Monmouth County. New Jersey
(CITY. STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Substance Abuse Counselor
B. TYPE OF INDUSTRY OR BUSINESS Health Care
15. PLACE OF BIRTH North Tarrytown, New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME William Edward Cioffiro
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Lucy Elaine Kocent
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL JllNNULMENT
o 0
DEATH
o
6. FATHER
A. NAME Wayne F Melish
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Ethel A. Jedlica
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 1
9. ~~~~~~tRM~FR~It&T8us MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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? DYES D NO
10. 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
YEAR
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) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
::;
::>
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1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH" 0 0 4TH
I du 'swear/affirm,'depose and say, thattothe best of my knowledge and belief that the information I provided is true and that I declare that
as to my right to enter into the mamage state. ....J~. '.
21. SIGNATURE OF GROOM~}(' ~ 'i'v/ ~ 22. SIGNATURE OF BRIDE~
USE N NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ D
This IIi:ense authorizes the marriage in New' State of the bride and groom named above by any person authorized by New York Domestic
W Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
en 0 If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
Z ~ 24. TOWN OR CITY CLERK . 25. A. SOLEMNIZATION PERIOD BEGINS
.~ } NAME (PRINT) John C. Masterson
:; {SEAL SIGNATURE ~ CJD C 11j tte...f+.- > DATE 04/25/200 TIME MONTH YEAR MONTH
'-v-I MAI~ ~r~ay;ei2sh Rd, Wappinger Falls, NY 12590 05:56~~ 04 26 2007 06 24 2007
STREET . CITYITOWN STATE ZIP
~~~~~RT~~J 'o~Oi~~N~~~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME O. DAY YEAR 0 ~LIGIOUS
DATE AND AT THE TIME AND AM /_
PLACE INDICATED. : ~~ PM CP Z. 0 7 9 0 OTHER, SPECIFY
29. OFFICIANT~""~ -:3A.~ k. VA~lt C<I'"7t,~.l:.
NAME (PRINT)"JUfJ"<... t TITLE p~~
SIGNATURE-'?1JAIA~~ tI~ DATE --:5'vw-o :1-.:z-o f> 7
MAILING AD&'RES'Wl , o~. '. ,
I if ro~. ., 11'#..1.$ 'J;!I). ~R-I~/1'VJApne.. /6..5; /:)
STREET L STATE
~.WITNESSTO~REMO~Y
NAME (PRINT) L' h ~ ( S
o
o
o
o
ent exists
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVil
A. STATE NEW YORK B. COUNTY V<!,.:!,11
1ts7
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~GE OF
SPECIFY 18 1<1 MeA-I;" /Yl41vo"e
ZIP
31. WITNESS TO CEREMONY
k/c
NAME (PRINT)
SIGNATURE~