159
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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~; 1368 '
~~~~J~R 159
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jason Thomas Pulcastro
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sara Kathryn Ward
MIDDLE CURRENT SURNAME
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1 , A, FULL NAME
11, A FULL NAME
FIRST
ll.
N
B, BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Pulcastro
(OPTIONAL - SEE REVERSE) 068-68-4453
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. Tennessee B Davidson
(STA!E} (COUNTY)
C. CHECK ONE IT CITY 0 TOWN 0 VILLAGE
~~~CIFY Nashville
D. STREET ADDRESS 5901 Old Hickory Blvd. ZIP 37016
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? r1 YES 0 NO
13. A. AGE 23 3B. DATE OF BIRTH 06 /08 ,/1983
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 073 66 1266
D. SOCIAL SECURITY NUMBER --
2 RESIDENCE A Tennessee B. Davidson
(STATEj (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~CIFY Nashville
D. STREET ADDRESS 5901 Old Hickory Blvd. ZIP 37076
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? cf YES 0 NO
02 / 26 / 1982
MONTH DAY YEAR
3. A. AGE 24
3B. DATE OF BIRTH
4. EMPLOYMENT
14. EMPLOYMENT
A. uSUAL OCCUPATION Teacher
B. TYPE OF INDUf?TRY OR BUSINESS Wilson Cntrl. High Schl.
15. PLACE OF BIRTH PoughkeepsIe, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME William Geor~e Ward
'B. COUNTRY OF BIRTH U S
17. MOTHER
A. MAIDEN NAME Kathryn Ann Witson
B. COUNlTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVBRCE CIVIL ANN8LMENT
A. USUAL OCCUPATION Security Supervisor
B. TYPE OF INDUSTRY OR BUSINESS. G~P I Inc.
5. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Anthony L. Pulcastro
B. COUNTRY OF BIRTH USA
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7. MOTHER
A. MAIDEN NAME SueAnn M. Paolilli
B. COUNTRY OF BIRTH USA
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8. NUMBER OF THIS MARF,lIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
..
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
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
C. DATE LAST MARRIAGE ENDED?
1ST 0 1ST 0 0
2ND 0 2ND 0 0
::; 3RD 0 3RD 0 0
0 0
hat I declare that no legal impediment exists
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23. SUBSCRIBED AND SWORN T IRMED BEFORE ME
SIGNATURE OF TOWN OR CI CLERK ~
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 CITYfc5hR~ C. Masterson 25. A SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
DATE
by New York Domestic
~
{ SEAL }
'-t-I
ZIP
09/28/200
DATE
Wappinger Falls, NY 12590
YEAR
MONTH
YEAR
2006
11
27 2006
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TYPE OF CEREMONY
~ RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY -y p'f;::..Le..S..r
c. LOCATION OF CEREMONY @
(CHECK ON~N~ SPECIFY) ~ I/'
o CITY OF ~OWN OF Q VILLAGE OF r I J
SPECIFY W 4~/) 7 e r- :;:::t:!J?J::1.
29. OFFICIANT
NAME (PRINT)
SIGNATURE~