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COUNTY Dutchess
CITYiTOWN Wappinger
~~J~~c~ 1368
n5~I~l~R 137
STATE OF NEW YORK
DEPARTMEI\IT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Lerov Richard Me Tarsnev. Jr.
MIDDLE CUFIRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
~
1. A. FULL NAME
FROM THE BRIDE
Samantha Deidfc Kassaw
FIRST MIDDLE Del1.dre CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Me Tarsney
(OPTIONAL - SEE REVERSE) "~A~-5603
D. SDCIAL SECURITY NUMBER ~
12 RESIDENCEA. New York B. Orenae
(STAlSl (COUN"'I
C. CHECK ONE C"r CITY 0 TOWN 0 VILLAGE
~~~CIEY Port Jervi$ .
D. STREET ADDRESS 10 Oak street
11. A. FULL NAME
FIRST
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 0"70-54-8649
D. SDCIAL SECURITY NUMBER 'f
2. RESIDENCE A. New York B Orange
(STAIil (COUNTY)
C CHECK ONE !:!I CITY 0 TOWN 0 VILLAGE
~~~CIFY Port Jervis
D ~~RE~ ~~~RESS 1 Desk street
ZIP 12771
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r't NO
04 /20 A96S
MONTH DAY YEAR
ZIP 12771
YES ~ NO
/1965
YEAR
13.B. DATE OF BIRTH
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
04 /30
MONTH DAY
13. A. AGE 35
3. A. AGE 39
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Accountant
B TYPE OF INDUSTRY OR BUSINESS cendant MobilItY
15. PLACE OF BIRTH PoughkeePSIe, New York
(CITY, STATE/COUNTRY IF NOT USA)
4. EMPLOYMENT
A. USUAL OCCUPATION Warranty Administrator
B. TYPE OF INDUSTRY OR BUSINESS Nissen, Kia or Mldcletown
5. PLACE OF BIRTH Staten Island, New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Leroy Richard Me Tarsney
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Marsha Claire Wiliams
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
D D
16. FATHER
A. NAME Saul D. Kassow
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Angella Perkins
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
D D
DEATH
D
DEATH
o
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (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 ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
C. DATE LAST MARRIAGE ENDED?
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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1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of rny knowledg and belief that the information I proVided~'sandthat I declare that nD legal Impediment eXists
as to my nght to enter into the marr e stat . ~ )
21 SIGNATURE OF GROOM ~ r &>' ~22 SIGNATURE OF BRIDE ~
~ . SE CURRENT NAME
23. ~~NS~T~~~DO~N,oO~06'~ 6'?vsgE L..od G... DATE 10112/2004
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 911 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o It checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CI~~LE~K 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) ulon. a J.
{TIME MONTH
SEAL SIGNATURE ~ ' DATE 10112/2004
'-.,,-I MA~~ebush Rd, ailS, NY 12590 02:41 ~~ 10
STREET CITYfTO N STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNiZATION OCCURRED 27. TYPE OF CEREMONY
~~~SM~=~~gEAB~V;Hci'N PitfE TIME MO DAY YEAR 0 ~ RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. /.' f!JQ M II 6 0 + 9 0 OTHER, SPECIFY
29. OFFICIANT (). f"<. IILJ N ~ ,..,.d P '_0 C!..l
NAME (PRINT) t::1"''''''~1 . ............ TITLE \ '" 'I ~~,.
~~,:,;,..w:5!.;'" ./ ~A.l;z ~ "" /1 - "-A<><>-}
1\ CJ ;V\~C:>v\ "'So\- cu.~?\V\~~v<S F<0J..<> ~:f. L~~~b
STREET CITYiTOW~ -'j STATE ZIP
30. WITNESS TO C ;;:;;Y/'~. t-Ie Z 31. WITNESS TO CE~EM Y
f NAME (PRINT)
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YEAR
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTB~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFY VV'u.Ff't\.~ -t/l"S IF' c}..l}.,->
SIGNATURE ~