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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Matthew J. Moss
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYrr"OWN Wappinger
~~J~kc~ 1368
~5~I~J~R 38
"DUPLICATE copy"
1. A FULL NAME
FIRST
BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 111 72 3858
o SOCIAL SECURITY NUMBER --
2 RESIDENCE A New York B. Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY d""TOWN 0 VILLAGE
~~~CIFY Wappinger
o STREET ADDRESS 1519 Route 376
ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ct NO
06 / 29 / 197
MONTH DAY YEAR
3. A. AGE 25
38. DATE OF BIRTH
4. EMPLOYMENT
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A USUAL OCCUPATION Highway Department
B. TYPE OF INDUSTRY OR BUSINESS Town Of Wappinger
5. PLACE OF BIRTH Valley Stream, Long Island, New York
(CITY. STATElCOUNTRY IF NOT USA)
6. FATHER
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A. NAME Jack Lee Moss
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Lucille Ann D' Arienzo
8. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
8. 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
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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jessica Anne Hait
~
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Moss
(OPTIONAL' SEE REVERSE) 080 68 9950
D. SOCIAL SECURITY NUMBER --
12 RESIDENCE A. New York 8 Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY O"';-OWN 0 VILLAGE
~~~CIFY Wappinger
o STREET ADDRESS 1519 Route 376 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ct NO
07 / 29 /1978
MONTH DAY YEAR
13. A. AGE 23
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Insurance
B. TYPE OF INDUSTRY OR BUSINESS Brinkerhoff & Neuville Ins.
15. PLACE OF BIRTH Beacon, New York
(CITY. STATElCOUNTRY IF NOT USA)
16. FATHER
A. NAME Donald Alan Hait
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Chervl Lee Morse
8. COUNTRY OF BIRTH USA
1
lB. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNUUMENT
/ /
(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
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15T 0 0 15T
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is
as to my right to enter into the marri e S te.
21. SIGNATURE OF GROOM.
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.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITGI~Ri 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
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{ SEAL }
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STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
DATE
by New York Domestic
TIME
MONTH
AM
12 :43>M
04
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNTY~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF l("TOWN OF 0 VILLAGE OF
SPECIFY l ~, w. !,.r
M oS..s
SIGNATURE.