165
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Matthew Clinton Rockett
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c: 1368 .
~5~I~J~R 165
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Michelle Margiotta
MIDDLE CURRENT SURNAME
11. A. FULL NAME
1. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Rockett
(OPTIONAL - SEE REVERSE) 116-72-0785
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B Dutchess
(STATE) -wi (COUNITY)
C. CHECK ONE 0 CITY LJ TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 19 1 A Vandldoort Dnve ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d NO
13. A. AGE 30 3B. DATE OF BIRTH 09 /19 /1976
MONTH DAY YEAR
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 097 62 6437
D. SOCIAL SECURITY NUMBER --
2 RESIDENCE A. New York B. Dutchess
(STATE) (COUNITY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 19 1 A Vandidoort Drive
+
ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r:1 NO
06 / 07 / 1975
MONTH DAY YEAR
3. A. AGE 31
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION EFT Specialist
B. TYPE OF INDUSTRY OR BUSINESS Contractors Register, Inc.
15. PLACE OF BIRTH NewRoche!le, New York
(CITY, STATE I COUNTRY IF NOT USA)
4. EMPLOYMENT
A. USUAL OCCUPATION Teller Supervisor
B. TYPE OF INDUSTRY OR BUSINESS Hudson Valley FCU
5. PLACE OF BIRTH Carmel, New York
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Timothv DouQlas Rockett
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Harriet Doren Hodge
B. COUNTRY OF BIRTH USA
1
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
16. FATHER
A. NAME Anthony Thomas Margiotta
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Vivian Rose Maiure
B. COUNTRY OF BIRTH USA
1
1 B. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL AN~LMENT
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
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20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
OATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNITY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
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) (CITYICOUNITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
0 0 0 0
0 0 0 0
0 0 0 0
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USE CURRE NAME
23. SUBSCRIBED AND .SWORN TO/AFFIR ED BEFORE ME
SIGNATURE OF TCDWN OR CITY ClE K ~
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 ,cLI'RK C M t 25 A SOLEMNIZATION PERIOD BEGINS
r- ~ JOnn . as erson . .
{ } NAME (PRINT)
SEAL SIGNATURE ~ DATE 10/11/200 TIME
MAIL~e"lOO'ffi:l ,Wappinger Falls, NY 12590 ,.jI.M 10
'-v-' 06:1i>M
DATE
by New York Domestic
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YEAR
MONTH
YEAR
MONTH
12
2006
12
ZIP
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STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
2B. PLACE WHERE MARRIAGE OCC~
A. STATE NEW YORK B. couN~U.1C:~
c. LOCATJON OF CEREMONY
(CHjlK ONE AND SPECIFY)
r/CIT'f~-fi!t-':pWN OF 0 VILLAGE O~
'0 SPECIFY 175" ~ ~'if'(' /~
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NAME (PRINT)
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NAME (PRINT)
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