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1 A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Kevin Thomas Walsh
FIRST MIDDLE
::> I A II:. riL.l:. NUMtU:H
(THIS SPACE FOR STA TE USE ONL Y)
COUNTyDutchess
CITY/TOWN Wappinger
~~~~~c~1368
~5~I~J~R40
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME Melissa Joan Serraro
FIRST MIDDLE
CURRENT SURNAME
11. A
CURRENT SURNAME
8 BIRTH NAME. IF DIFFERENT
e BIRTH NAME (MAIDEN NAME), IF DIFFER~T
C SURNAME AFTER MARRIAGE Wals
(OPTIONAL - SEE REVERSE)122 -66-5214
o SOCIAL SECURITY NUMBER 0 t h
12. RESIDENCE ANew York B u cess
(STATE) '" (COUNTY)
C. CHECK c!'1'jf, 0 CITY r:;L To.WN 0 ViLLAGE
~~~CIFyVVapplngers r-alls
1350. Gilmore Blvd.
o STREET ADDRESS
C SURNAME AFTER MARRIAGE
{OPTiONAL SEE REVERSElt 21 66-5586
D SOCIAL SECURITY NUMBER I -
2 RESiDENCE A New York 8 Dutchess
(STATE) t.L (COUNTY)
C CHECK ONE 0 CITY 0 TOWN U VILLAGE
~~~CIFY Wappingers Falls
D STREET ADDRESS 13 50. Gilm ore Blvd.
ZIP 125!:1U
.;
E is RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
03 /21
DAY
E is RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
13 A. AGE23 13.8. DATE OF BIRTH 03 ,14-
MONTH DAY
1~NO
YEAR
A AGE 16
YES 0 NO
/1980
YEAR
3B. DATE OF BIRTH
MONTH
14. EMPLOYMENT .
A USUAL OCCUPATION Hair Stylist
Dana Cole Salon
B. TYPE OF INDI..!~T.fl'(itOR ~SIIIIESS .... o't.
vvn e ~Ialns new Y 011\,
15. PLACE OF BIRTH '
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A NAMEFrank Dan Serraro
B. COUNTRY OF BIRTHU 5 A
17. MOTHER M M 0 h
Margaret . c onoug
A. MAIDEN NAME
B. COUNTRY OF BIRTHU S ~
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DllfRCE CIVIL A"fjULMENT
DF() TH
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4. EMPLOYMENT
A. USUAL OCCUPATION Contractor
B TYPE OF INDUSTRY OR BUSINESS OWn Business
5. PLACE OF BIRTH Cortlandt, New York
(CITY, STATE/COUNTRY IF NOT USA)
6 FATHER
A NAME Thomas Michael Walsh
B. COUNTRY OF BIRTH U 5 A
7. MOTHER
A. MAIDEN NAME Kathleen Theresa Johnson
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
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRiAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? 13) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D ARE ANY FORMER SPOUSEIS) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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18T 0 0 18T
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
t, being duly sworn, depose and say, that to the best of rny knowledge and belief that the information I provided is true and th
as to my right to enter into the marriage state.
21 SIGNATURE OF GROOM ~ c::>""(
U
23. SUBSCRIBED AND SWORN TO BEFORE ME
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
Relations Law 911 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) John C. Mast rson
YEAR
SEAL SIGNATURE ~.. DATE 04/28/2006
'-v-I MA~B~~d~s ush Rd, appinger Falls, NY 12590
STREET CITYfTOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER- - --'"
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~RELlGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. PM
29. OFFICIANT . "-r If)' l (
NAME (PRINT) '-"() h V\ f'.,.e..l -;;; A
SIGNATLlRE~ e-~ ~ ~
MAILING ADDRESS J- ~ /J /~ IL(
IfF CtA.'('(JeY1.-{~r- f\I;(. v~_ e ·
STREET I CITY/TO
30. WITNESS TO CEREMONY
S oo..N,
DATE
by New York Domestic
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YEAR
06
21 2006
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B COUNTY ':.c~l te-le~
9 0 QTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
TITLER.DW\AYlt.~{ic. ~cc i-\
DATE 6/3/ tP-6
yVy.
o CITY OF L\V1'OWN OF 0 VILLAGE OF
SPECIFY E 11.rl F j'.!!,' ~ It'; Ii.
/~s 33
STATE
31.
N\- ('"r't,t rle (
.~ \,<\, M~~
SIGNATURE ~
NAME (PRINT)