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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c; 1368 .
~~~~~~R 164
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rnhert HnwC'lrrl Fortier
MIDDLE CURRENT SURNAME
FIRST
,
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Theresa Ann Kostik
MIDDLE CURRENT SURNAME
-.J
1 . A. FULL NAME
11. A. FULL NAME
FIRST
0..
N
B. BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE Fortier
D. S~:;':'~~~~'~~U~~~~RSE) 118-64-3141 D. S~~:I~~~~~E~U~~~~RSE) 096-70-0086
2. RESIDENCE A New Ynrk B Dutchess 12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY) (STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinger ~~~CIFY WappinQer
D. STREET ADDRESS 4 Martin Drive ZIP 12590 D. STREET ADDRESS 4 Martin Drive 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 t1' NO
3. A. AGE :i!'i 3B. DATE OF BIRTH 1? / 25 / 1970 13. A. AGE 34 3B. DATE OF BIRTH 10 /28 /1'971
MONTH DAY YEAR MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Electrician
B. TYPE OF INDUSTRY OR BUSINESS Local 3
5. PLACE OF BIRTH Cortlandt. New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Edward Joseph Fortier
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Judith Claire COX
B. COUNTRY OF BIRTH USA
B. 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 Technical Assistant
B. TYPE OF INDUSTRY OR BUSINESS LPE Enterprises
15. PLACE OF BIRTH Yonkers, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Joseph Kostik
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Margaret Ryan
B. COUNTRY OF BIRTH USA
1 B. 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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/..........7
(gLQQlaT!L.. ._..JL!iQ):YJ2!Q..kiST ~!!BI,~ca5.!~~ ... ,(3)J;:J.RlygRc;E (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
MONTH DAY
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) (CITY/COUNTY, STATE/COUNTRY, IF No'l' USA) SELF SPOUSE
YEAR
21. SIGNATURE OF GROOM
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
~e and belief that the information I provided is true and that I declare tZO leg,a~c exists
22. SIGNATURE OF BRIDE~ / ~
USE CURRENT NAME
W
UJ
Z
W
(,)
:::::i
23. SUBSCRIBED,AND SWORN TO/AFFIRM BEFO
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law !l11 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) Jo n C. Masterson
{ / TIME MONTH YEAR MONTH
SEAL SIGNATURE~ DATE 10 10/200
'-v-I MAI~ ~Efd'fE appinger Falls, NY 12590 10:00AM 10 11 2006 12 09 2006
STREET CITYITOWN STATE ZIP PM
~~~~~RT~~J ~~O~~~Nif:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~LIGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. ~ 0 PM \ 0 \ "?:, ;Loo 9 0 OTHER, SPECIFY
29. OFFICIANT 7\ l "'\) 0
NAME (PRINT) J..)t;\ Ie, G.., 1"\. S@6e's>
SIGNATURE~ 'J)~. ~ r:R, &,~
MAILING ADDRESS 0-
la.. 10~~t'n~~~ B~...c,01n
STREET CITYfTOWN
30. WITNESS TO C~MONY
NAME (PRINT) e:::~w A
DATE
10/10/2006
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY-P~~.wL
TITLE CO _ \ e...r-IO "-
1 ,
DATE Oclc~ \~l '2~b
K.\ Y 1 "25"/\8
STATE ZIP
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY ~\i'fs\-rY\.l.W"
:::rQ ,
31. WITNESS TO CEREMONY
NAME (PRINT)iOVrL.l/ .uru z/ ~
SIGNATURE~ TOvf. fAA jj/lcif:t t2
SIGNATURE~
DOH-9B (0312006)