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CITYfrOWNWappinger
~~~~~ 368 '
~5~:J~'33
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Daniel John Reichert
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONLY)
I
SUPPLEMENTAL FILE
FROM THE BRIDE
Courtney Alysse Deserre
MIDDLE CURRENT SURNAME
..J
Lo
1. A. FULL NAME
11, A. FULL NAME
FIRST
FIRST
l1.
f;j
B, BIRTH NAME (MAIDEN NAM'hIF ~IFFfi'e'rt
C, SURNAME AFTER MARRIAGP'e c
(OPTIONAL - SEE REVERSQl01- f2-9U4o
D. SOCIAL ~1~1TY NUMBER Dutchess
12. RESIDENCE ~~ B.
(STATE) ~ (COUNTY)
C. CHEC~E hk'llD CITY 0 TOWN 0 VILLAGE
AND IS I
SPECI 3 T ,., F'\'
2 4 own view IJIIV~
D. STREET ADDRESS
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORfi~ VILLAGE;:I, ., 0
13. A. AGf6 3B. DATE OF BIRTH ~
MONTH DAY
14. EMPLOYMENT ~ b T h
~u - eac er
A. USUAL OCCUPATIO Education
B. TYPE OF INQUI3TRY QR BU~ESS
HouStOn I exas
15. PLACE OF BIRTH '
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER .
M~teven FranCIS Deserre
,A. NA ~ LJ SA
B. COUNTRY OF BIRTH
v
~~4 NO
YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSIil.97 -70-3497
0, SOCIAL SECURITY NUMBER U
2. RESIDENCE ANY B.Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CI#D TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRE~34 Town View Drive ZIP 1259U
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEt 0 NO
01 /07 /1985
MONTH DAY YEAR
12590
ZIP
3. A. AGF25
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Network Enoineer
B. TYPE OF INDUSTRY OR BUSINESS Telecoms
5. PLACE OF BIRTJ"ehioh , Pennsylvania
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Robert John Reichert
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Janice Nettleton
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. ~~~~I9~~R~~h1Wgus MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
17. MOTHER J-:' J M t'
Isa ane on Ie
A. MAIDEN NAM S
B. COUNTRY OF BIRT~ ~
1B. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
~VORCE CIVIL ~NULMENT
OO^TH
DOATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
, ~ - YEAR
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
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
to
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF OECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3AD 0 0 3AD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the marrra~st te. ....--
21. SIGNATURE OF GROOM" 22. SIGNATURE OF BRIDE"
USE cu
23. SUBSCRIBED AND SWORN TO/AFFIRMED 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) John C. Masterson
{ SEAL SIGNATURE~ DATE 04/22/2010 YEAR
'-v-I MA~eGrOO~d S , NY 12590
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
by New York Domestic
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
ZIP
YEAR
06
21 2010
l~VIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~~T'tJoftd
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND ~CIFY)
o CITY OF cyfoWN OF 0 VILLAGE OF
SPECIFY~Ll t... ~ ~....,~ Ii..