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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~ 1368 '
~~~I:J~R 7
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.r-
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Marisa Marie Schmidt
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Ra i mond i
c. SURNAME AFTER MARRIAGE Cheney
(OPTIONAL - SEE REVERSE) 119 74 1063
D. SOCIAL SECURITY NUMBER --
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY [!" TOWN d VILLAGE
~~~CIFY Waooinaer
D. STREET ADDRESS 304 Chelsea Cay
1. A. FULL .NAME
Scott Patrick Chen~
MIDDLE CURRE SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT '.
C. SURNAME AFTER MARRIAGE
(OPTIONAL -'SEE REVERSE) 081 72 6745
D. SOCIAL SECURITY NUMBER - - .
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY IS1'J' TOWN 0 VILLAGE
AND W .
SPECIFY' .' appmgE;)r
D. STREET ADDRESS 304 Chelsea Cay
ZIP
12590
ZIP 12590
YES c1 NO
/1979
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY DR INCORPORATED VIlLAGE? 0
13. A. AGE 27 3B. DATE OF BIRTH 04 / 03
MONTH DAY
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE ?fi 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS WCSD
5. PLACE OF BIRTH Saranac Lake. New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME . Jeffery Eugene Cheney
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary Margaret O'Donnell
B. COUNTRY.OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 1
o YES~NO
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B.. TYPE OF INDUSTRY OR BUSINESS WCSD
15. PLACE OF BIRTH Goshen. New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME -Joseph Michael Raimondi
'B. COUNTRY OF BIRTH USA
17: MOTHER
A. MAIDEN NAME Marie Ellen Mills
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE . CIVIL ANNULMENT
1 0
B. HOW DID lAST' MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) ODEA'j'H B, HOW DID lAST MARRIAGE END? '(3) dIolVORCE '. . (310 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGEENDED? / / C.DATE LAST MARRIAGE ENDED? . 01 / 05 / 2007
MONTH DAY YEAR MONTH DAY"- YEAR
D. ARE ANY FORMER SPOUSE(SI ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? [r<.ES 0 NO
..
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) (CITY/COUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 01/05/2007 Goshen. New York 0 r1
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, dep.ose and'say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into themamage state. . . . . . . '. . P _ /L t
21. SIGNATURE OF GROOM" '7 22. SIGNATURE OF BRIDE" ~ .,l.':'-::>Q....; 0(!-rVYJ? ..Idt:-
USE cu USE CURRENT NAME
23. SUBSCRIBED,AND,SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the mamage in New Yo State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit in New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used ani for the purpose of a second or subsequent ceremony.
r-I'-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ . .} NA.ME (PRINT) J n C. Masterson TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ DATE 02/01/200
'-v-/' . MAIL~8"lOO2fa in er Falls NY 12590 03:1~~ 02 02 2007 04 02 2007
STREET CITYITOWN STATE ZIP
~~~R~:RT:J lo~O~~N~zi~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME DAY YEAR 015 RELIGIOUS
DATE AND AT THE TIME AND ~ AM .... I) 7
PLACE INDICATED. GJ~ ' v".. 17 (j 90 OTHER, SPECIFY
9, PREVIOUS MARRIAGES .
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
02/01/2007
DATE
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY]>l(frHJI'?5.>
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o crT" OF !K'TOWN OF 0 VILLAGE OF
SPECIFY A ~.#J<JL.. (... - F~N-J:..~a..
1!7(4-Prl~ CJ+.I~w--,
~~Jn~~~J;>~~ TITLE7~JI/Alu ~t'L
SIGNATURE~'" ~.~~I.A.- n~ ..2//7/41'
MAILING ADDRESS, "
tJ.5 S()#t1>-7 ;;;P.IV~ r:3I.1t""..,~EY;;-Pt;,FS.- AJ,/
STREET CITYfTOWN STATE
30. WITNESS TO CEREMONY 31. WITNESS T
I~~~
. ZIP
NAME (PRINT)
SIGNATURE ~..,
DOH-98 (03120061