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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~~ F. Tr~=NT SURNAME
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I, being duly sworn, depose and say, that to the best ot my knowledge and be iet that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the ~r~8Qe state. ~--..
21. SIGNATURE OF GROOM ~ \S.~ 22. SIGNATURE OF BRIDE ~ . L P.Ii. ~~
USE CURRENT NAME
23. ~~;~T~~~DO~N~~~O~~ ci~Bg~~~E DATE 101D4/2004
This license authorizes the marriage in New York te of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license i 0 be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY ~
CrfyrrOWN Wappinger
~~J~~~ 1368
~~~~J~R 132
1. A. FULL NAME
FIRST
a.
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 134-7~2323
D. SOCIAL SECURITY NUMBER ___,
2. RESIDENCE A. New York B. Dutchf!!llR
(STml (COUNTY)
C. CHECK ONE 0 CITY ~OWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 36 Falrvlew Road ZIP 12508
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIULAGE? 0 YES r:JI" NO
3. A. AGE~ 38. DATE OF BIRTH~I' 11 / y!W=1
4. EMPLOYMENT
A. USUAL OCCUPATION
Iron Worker
l...oo8I 40
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH (~~~NT~O~~
6. FATHER
A. NAME Lawrence Travers
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Stephanie Lebey
8. COUNTRY OF BIRTH CAnada
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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 NOTUSA) SELF SPOUSE
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{ SEAL }
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STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Theresa M. Massi
MIDDLE CURRENT SURNAME
-.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Travers
(OPTIONAL - SEE REVERSE) 11 ~ '72' rr739
D. SOCIAL SECURITY NUMBER _ _ ~~~-
12. RESIDENCEA. ~Erork B. q~ess
C. CHECK ONE 0 CITY D"'OWN 0 VilLAGE
AND 'AI-.
SPECIFY VYllpplogers
D. STREET ADDRESS 11 Quarry DrIve ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Cl"NO
13. A. AGE 25 13.B. DATE OF BIRTH n":t / If7 /1Q79
~ mY m.-R
14. EMPLOYMENT
A. USUAL OCCUPATION Custom Picture Framer
B. TYPE OF INDUSTRY OR BUSINESS The Fram8iy
15. PLACE OF BIRTH arornc New Vork
(CITY. STATtCOUNTRY IF NOT USA)
16. FATHER
A. NAME R~mond MJIIIRi
8. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Susan M, Berry
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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
TIME
NAME (PRINT)
SIGNATURE ~ -
MAILING ADQRESS
MONTH
YEAR
ZIP
AM
12:25'M
10
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
o ~L1GIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~T~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF []<LAGE OF
SPECIFY WAP""~NGe"eS {'fJrfJ.,s
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
, ; ~ ~ 10 ~3 of
~~tSt~~~~T 1'1S6Y~. f'/<Ilr/c'.is? BE'Ll,/7W
iff: I . fJ i:J /1? -
SIGNATURE ~ "= ~ r fJrzW-W
MAILING ADDRE S A.L, {'
/ C - '. . "o.r. f/lJ 0.
STREET CITYrr
30 WITNESS TO ~E MONY
NAME (PRINT) ~ -Ja,~O;M ~
SIGNATURE~ ~ ,,.~
DOH-98 (11/98)
TITLE
~. C. t}~//?;r
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NAME (PRINT)
SIGNATURE ~