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COUNTY Dutchess
CITYrrOWN WappinQer
~~~~~c; 1368 .
~~~~;~R 1 72
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.John ~Wi;:)m Fre~~J~TVJlNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
N"r
USW
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Lisa Marie Russo
MIDDLE CURRENT SURNAME
.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE Fretwell
(OPTIONAL - SEE REVERSE) 053 72 0812 (OPTIONAL - SEE REVERSE) 052 70 3955
D. SOCIAL SECURITY NUMBER ___ - _ - __ D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. New York 8. Dutchess 12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY) (STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE C. CHECK ONE 0 CITY rot TOWN 0 VILLAGE
~~~CIFY Wappinger ~~~CIFY Wappinger
o STREET ADDRESS 15E Surrey Lane ZIP 12590 D. STREET ADDRESS 15E Surrey Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE ~4 3B. DATE OF BIRTH 08 / 08 / 1972 13. A. AGE 22 3B. DATE OF BIRTH 01 /09 /f 984
MONTH DAY YEAR MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS Thornwood Carwash
5. PLACE OF BIRTH Cortlandt. New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME John William Fretwell Sr
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Joanne Mary Erbaio
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
14. EMPLOYMENT
A. USUAL OCCUPATION T elema rketer
B. TYPE OF INDUSTRY OR BUSINESS Greyhouse Publishing
15. PLACE OF BIRTH Bronx, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Frank Russo
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Laura Ann Acheson
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
C. DATE LAST MARRIAGE ENDED?
1ST
2ND
3RD
4TH
I duly swear/affirm. depose an
as to my right to enter into the
21. SIGNATURE OF GROOM ~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
ledge and belief that the information I provided is tru a
o 0
o 0
o 0
o 0
o I gal impediment exists
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23. SUBSCRIBED AND SWORN TO/A I
SIGNATURE OF TOWN OR CITY C
This license authorizes the marriage in New 'York State of the bride and groom named above by any person authorized
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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) J n C. Mas erson
TIME MONTH YEAR
SEAL SIGNATURE. DATE 1 0/25/200
"- ~ MAli.Jt'I~ &0.01 R,E$~ AM
-v- LU MIOCll in er Falls, NY 12590 05:21PM 10
STREET CITYITOWN STATE ZIP
~~~R~~RT~J IO~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. PM 9 0 OTHER, SPECIFY
24 2006
DATE
10/25/2006
by New York Domestic
MONTH
YEAR
26
2006
12
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
TITLE
o CITY OF 0 TOWN OF 0 VILLAGE OF
SIGNATURE.
MAILING ADDRESS
DATE
SPECIFY
STREET
30. WITNESS TO CEREMONY
CITYrrOWN
ZIP
31. WITNESS TO CEREMONY
STATE
NAME (PRINT)
SIGNATURE.
DOH-98 (03/2006\
NAME (PRINT)
SIGNATURE.