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COUNTY Dutchess
CITYrrOWN Wappinger
~~J:~~ 1368 '
~5~1:J~R 78
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Scott Fredrick Wall
MIDDUO CURRENT SURNAME
STATIC 1"lU: NUMHICH
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Debra Ann Cluess
FIRST MIDDUO CURRENT SURNAME
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT Ostertaa
c, SURNAME AFTER MARRIAGE Wall
(OPTIONAL - SEE REVERSE) 109-66-2796
0, SOCIAL SECURITY NUMBER
12, RESIDENCE A, New York B, Dutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY r:f TOWN 0 VILLAGE
~~CIFY Poughkeepsie
0, STREET ADDRESS 11 Carnelll Court ZIP 12603
E, IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 6 NO
07 /14 /1969
MONTH DAY YEAR
1 , A, FULL NAME
11, A, FULL NAME
FIRST
..
N
B, BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1 06-64 3475
0, SOCIAL SECURITY NUMBER -
2, RESIDENCE A. New York B, Dutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY r!1 TOWN 0 VILLAGE
~~CIFY PouQhkeepsie
0, STREET ADDRESS 11 Carnelli Court ZIP 12603
E, IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
11 / 07 / 196
MONTH DAY YEAR
13, A. AGE 36
3. A, AGE 37
3B. DATE OF BIRTH
3B. DATE OF BiRTH
4. EMPLOYMENT
A, USUAL OCCUPATION Teacher
B, TYPE OF INDUSTRY OR BUSINESS W. C. S. D.
PLACEOFBIRTH Niskayuna, New York
(CITY, STATE I COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Certified Nurses Aide
B. TYPE OF INDUSTRY OR BI,ISINESS Health Industry
15. PLACE OF BIRTH PoughKeepsie, New York
(CITY, STATE I COUNTRY IF NOT USA)
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5.
6. FATHER
A. NAME Fredrick Hart Wall
B. COUNTRY OF BIRTH USA
16. FATHER
A. NAME Robert L. Ostertag
'B. COUNTRY OF BIRTH USA
17, MOTHER
A, MAIDEN NAME Ann M. Flynn
B. COUNTRY OF BIRTH USA
2
18, NUMBER OF THIS MARRIAGE
7. MOTHER
A. MAIDEN NAME Carol Soriano
B, COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
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9. ~~~~~~R~r~h~8us MARRIAGES WHICH ENDED BY 19, ~~~~~~~RM~FR~If~8us MARRIAGES WHICH ENDED BY
DIV01CE CIVIL ANNOLMENT DEACr DIV~RCE CIVIL AN~LMENT
.~ ~
B, HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT 208.fEAlH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORC11 (3) 0 ~~ULMENT 2dHs DEATH
c, DATE LAST MARRIAGE ENDED? 06/ 15 / C. DATE LAST MARRIAGE ENDED? / /
MONTH"", DAY YEAR MONTH !II DAY c. - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 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
(MONTHA DAY~Y~) (CITYJCqUNTY. STATE/POUNIJ\Y, IF NqT,USAk SELF SPOUSE (MPIjT~ QA,Y2'tFAFll plClTYlCpllNlY, STATElCOUI'{l'flY, IF NPJ U~t SELF SPO,E
1ST 06/ 15/~uu1 Pougnkeepsle, New Yor D~ 0 1ST ll/L11 UUO ougnKeepsle, I'\lew YOrK 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affinn, depose and sa . eUef that the Information I provided is trukj d that I declare that no legal impediment exists
as to my right to enter into the ,..J C. fJ
21. SIGNATURE OF GROOM~ ' 22. SIG ATURE OF BRIDE~ 1.LhAfA..- (// . JI J.1 0 ~
23, SUBSCRIBED AND SWORN TOIAFARMED BEFORE ~:E CU E ' USE CURRENT NAME 06/22/2006
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of by New York Domestic
Relations Law ~11 to perfonn marriage ceremonies within New Yo
o If checked, this license is to be us
~ 24. TOWN OR CITY ,QI,J:RK
NAME (PRINT) .Jonn C. Masterson
{SEAL} SIGNATURE ~ .
MAI~ 'lefl~fe
'-.t-I
D'1)H
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
08
21 2006
TIME
MONTH
YEAR
MONTH
YEAR
CITYITOWN
26. SOLEMNIZATION OCCURRED
IME A YEA
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
ZIP
02:1~~
06
23
2006
28. PLACE WHERE MARRIAGE OCCURRED
1 ~CIVIL
A. STATE NEW YORK B. COUNTY 1)l.ol.4-c~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY r-a"U "-.'~Sl 'c
AM
I/(J.)
07
aJ <<>2dJb
29.0FFICIANT~. .ffZ
NAME (PRINT)_ _ _'====
SIGNATURE ~
MAILING AD~
tfRE'f? l!"A~ . /lo{ crr~~~~hect,-
30, WITNESS TO EMONY
NAME (PRINT)
SIGNATURE~
OOH-98 (0312006)
TITLE
DATE
t-"'7
STATE
NAME (PRINT)
SIGNATURE~