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couNTYDutchess
CITYfTOWN Waooinoer
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
David Evan Wallach
MIDDLE CURRENT SURNAME
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONL Yi
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jessica Leigh Miuccio
MIDDLE CURRENT SURNAME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE!.
D. SOCIAL SECURITY NUMBER I 04-58-9222
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITWtJ TOWN D VilLAGE
AND L
SPECIFY agrange
D. STREET ADDRESS 136 Strinoham Road; Apt ZIP 12540
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VILLAGE? D YE~D NO
3. A. AGE40 3B. DATE OF BiRTH 05 /20 /1969
MONTH DAY Y~R
4. EMPLOYMENT
A. USUAL OCCUPATION Nuclear Security Officer
B. TYPE OF INDUSTRY OR BUSINESS Enerov
5. PLACE OF BIRTH Oceanside . NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Abraham Wallach
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Merle Carole Tendler
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARI:lIAGE 1
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGEWallach
(OPTIONAL. SEE REVERS~ 16-70-1507
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ~Y putchess
(STATE) (COUNTY)
C. CHECK ONE D CITY""b TOWN D VilLAGE
~~~cl~agrange
D. STREET ADDRESJ 36 stringham Road; Apt 5b ZIp12b4U
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYEs"'" D NO
13. A. AGe43 3B. DATE OF BIRTH 08 )'0 )-986
MONTH DAY Y~R
14. EMPLOYMENT
A. USUAL OCCuPATloJntake Specialist
B. TYPE OF INDUSTRY OR BUSINESsNon-Proflt
15. PLACE OF BIRTHY onkers, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMELouis Vincent Miuccio
'B. COUNTRY OF BIRTM S A
17, MOTHER
A. MAIDEN NAME Elizabeth Mary Ramsey
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
9, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
Dff'TH
DEATH
o
(3) D ANNULMENT (2) D DEATH
/ /
.'- Y~R
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C, DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID lAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
MONTH DAY Y~R
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) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
1ST D D
~D D D
3RD D D
~ D D
the information I provided is true and that I declare thal no legal impediment exists
:SIGNATURE OF BRIDE. ~/'(~ ~ M \ .
t:/ USE CURRENT N~ C::::I
DATE 04/27/201 0
D
D
D
c
~
t;
W
~
by New York Domestic
1ST
2ND
3RD
4TH
I duiy swear/affirm. aep'ose and say, that to the best of
as to my right to enter into the arnage state, ,
21. SIGNATURE OF GROOM.
SE CUR
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Yo State of the bride and groom named above by any person authorized
W Relations Law ~11to perform marriage ceremonies within New York State, THIS LICENSE VALID IN NEW YORK STATE ONLY,
en D If checked, this license Is to be used only for the urpose of a second or subsequent ceremony.
Z ~ 24, TOWN OR CITY CLERK 25, A. SOLEMNIZATION PERIOD BEGINS
W { } NAME (PRINT) John . Masterson
o TIME MONTH YEAR
::; SEAL SIGNATURE ~' DATE 04/27/2010
MAILING ADDRE~S
'-.,-' 20 Middle sh Rd. WappinQers Falls, NY 12590
STREET CITY/TOWN STATE ZIP
~~~R~~RT~~~ IO~O~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME AY YEAR 0 D RELIGIOUS l~CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 D OTHER, SPECIFY
29.0FFICIAN,"'?
NAME (PRINT) <1,.'"
MONTH
YEAR
06
26 2010
12:57:~ 04
28
2010
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B, COUN;b~.,.c. ~
SIGNATURE ~
MAILi,AD
STREET
30. WITNESS TO C
NAME (PRINT)
SIGNATURE~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF D TOWN OF ri'LAGE OF
SPECIFY WAfJP, ~ tttS ~
'TN
NAME (PRINT)
SIGNATURE~
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