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1. A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mihai Octavian Druta
CURRENT SURNAME
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITYITOWN Wappinger
~~~~f~ 1368
~5~I~J~R 77
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Roisin Michele Knapp
FIRST MIDDLE
11. A. FULL NAME
MIDDLE
CURRENT SURNAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Druta
(OPTIONAL. SEE REVERSE) 111:.64-8556
D. SOCIAL SECURITY NUMBER ..,.. ----
12. RESIDENCE A New York B Dutchess
(STATE) ~ (COUNTY)
C. CHECK ONE 0 CITY IT TOWN 0 VILLAGE
~~~CIFY Wappinaer
D. STREET ADDRESS 1668 Route 9 Apt. 13 C
B BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
O. SOCIAL SECURITY NUMBER
2 RESIDENCE A New York B Dutchess
(STATE) J (COUNTY)
C. CHECK ONE 0 CITY D TOWN 0 VilLAGE
AND W .
SPECIFY applnger
o STREET ADDRESS 1668 Route 9 Apt. 13 C ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 1'1 NO
06 /05 /1978
MONTH OAY YEAR
n/a
ZIP 12590
DYES !1 NO
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YEAR
3 A. AGE 27
3B. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 25 13.6. DATE OF BIRTH D1 AD
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS Choco Vision Corp.
15. PLACE OF BIRTH Pouohkeeosie, New York
(CITY. ~TATElCOUmRY IF NOT USA)
16. FATHER
A. NAME Walter Vincent KnapP. Jr;
B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Amanda Harwond Mnlp.
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
o
4. EMPLOYMENT
A. USUAL OCCUPATION Network Administrator
6. TYPE OF INDUSTRY OR BUSINESS Vemas Foundation
5. PLACE OF BIRTH Sighisoara, Romania
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
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A. NAME Vasile Druta
B. COUNTRY OF BIRTH Romania
7. MOTHER
A. MAIDEN NAME Marianne Doris lutsch
B COUNTRY OF BIRTH Romania
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
6. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) 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 FOLlLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
pediment exists
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I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and t t I declare that nD leg I'
as to my right to enter into the marriage slate. I -....J e ( /
21. SIGNATURE OF GROOM ~ R \ ~ f) W W..J
U USE CURRENT NAME
DATE
by New York Domestic
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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 ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY lERIS... 25. A, SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) jJ l,;. Masters n TIME MONTH YEAR
{SEAL SIGNATURE ~ ' DATE 07/2812005
~ M1ft'MfCl ppinger Falls, NY 12590 12:43 ~~ 07 29 2005
STREET CITYfTOWN STATE ZIP
~~~R~~~Ri~~~ IO~O~~N~zEE~ 26 SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~ELlGIOUS
DATE AND AT THE TIME AND I ~ 5
PLACE INDICATED. P 7 - 30 - 0 9 0 OTHER, SPECIFY
29. OFFICIANT n~l r 1 ~
NAME (PRINT) -1::::l..- d-::::>
SIGNATURE ~
MAILING ADDRESS _.
3" ft r- wt II. ~ IUd., fnvsL.. ,~.."~:..
STREET (:ITYITOWN'"
30 WITNESS TO CEREMONY
09
26 2005
MONTH
YEAR
1 D CIVil
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTyDuTcA67
TITLE .lts7'.
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF D V~LAGE OF
SPECIFY ~k.e<")p71(J
NAME (PRINT)
SIGNATURE ~