039
+
~
alii
~
co
to
o
1-1- ~
~() 5:
W <
III C
9::lw~
5.o~ u.
ilic::::l....
z to i '"',
soo
~ ~
!!!t::o
Cl::l
ll'o
l!l()
<-
~ro
~u
LLW
o.!:
~m
()
~C"')
a: ~
W
()
W
a:
W
~
~
W
a:
o
o
<
~
irl
ll.
Ul
a:'
w
~
:>
z
Q
~
Iii
w
~
w
-en
z
-W
(.)
-::i
+
~~~ W
~~;::
a:"';:S ~
lii~~ (.)
:>()W
::;:Cl5 ~
I-ZUl
~~~ ~
iEOUl W
~~~ (.)
l!!ffi",
~g~
1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Jas~rol~cott Fur~~I:NTSURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
COUNTY Dutchess
CITY/TOWN Wappinger
~~J:~C:1368 .
~5~~J~R39
.J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Andrea Nicole Masiello
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
"-
F'I
B. BIRTH NAME. IF DIFFERENT
B, BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGEF u rg ala
(OPTIONAL - SEE REVERS'e>57 -7 4-6023
0, SOCIAL SECURITY NUMBER
12, RESIDENCEA9T {airfield
(S~TE) (COUNTY)
C, CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~~cl~anbury
D. STREET ADDRESJ 3 Brmscall Court ZIP6tl1 U
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? .....0 YES 0 NO
13, A. AG~ 1 3B. DATE OF BIRTH 12 fJ7 )-978
MONTH DAY YEAR
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEb98 66 9179
0, SOCIAL SECURITY NUMBER --
2, RESIDENCE A, CT B. Fairfield
(STATE) (COUNTY)
C, CHECK ONE lit! CITY 0 TOWN 0 VILLAGE
~~~CIFY Danbury
0, STREET ADDRESS 13 Brinscall Court ZIP 06810
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? "6 YES 0 NO
02 /29 /1976
MONTH DAY YEAR
3. A. AGE 34
3B, DATE OF BIRTH
4. EMPLOYMENT
A, USUAL OCCUPATION Accountant
B, TYPE OF INDUSTRY OR BUSINESS Accounting
5, PLACE OF BIRTHBuffalo. Nv
(CITY. STATE I COUNTRY IF NOT USA)
14. EMPLOYMENT
A, USUAL OCCUPATIO~ocial Worker
B. TYPE OF INDUSTRY OR BUSINESSSoclal Work
15, PLACE OF BIRT~rooklyn, Ny
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEThomas Masiello
. B. COUNTRY OF BIRJJ S A
17, MOTHER
A. MAIDEN NAMEGretchen Wallace
B, COUNTRY OF BIRTM S A
18. NUMBER OF THIS MARRIAGE 1
19, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
6, FATHER
A. NAME Robert Furgala
B, COUNTRY OF BIRTH USA
7, MOTHER
A. MAIDEN NAME Bonnie Miller
B, COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DOATH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW 010 LAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.,- YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 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
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
of my knowledge and belief that the information I provided is true and that I declare that
USE CURRENT
23, SUBSCRIBED AND SWORN TO FFIRMED 8EFORE 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) Joh . Masterson
{ ~ ~ ~
SEAL SIGNATURE ~ (, .' DATE 04/28/201 0
'-..t-I MA~15GrOO'lfdr~b h Rd, Wappingers Falls, NY 12590 12:03:~ 04 29 2010
STREET CITY/TOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26 SOLEMNIZATION OCCURRED 2~TYPE OF CEREMONY
THE MARRIAGE OF THE PER- .
SONS NAMED ABOVE ON THE TIME M , AY YEAR 0 RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND A I J .
PLACE INDICATED. P .s-. ')./, /0 90 OTHER, SPECIFY
17 f-1 L-, .,.0
DATE
by New York Domestic
MONTH
YEAR
06
27 2010
28, PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 'J},Jr(;J, oS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF Jq-TOWN OF 0 VILLAGE OF
SPECIFY U~PJ'; nt;t Cy
'1 If
29, OFFICIANT
NAME (PRINT)
TITLE ~
DATE S-/.:z-/j/O
fl. y. 1.:2.-s-9 t!)
ZIP
CEREMONY
STATE
nnU_OA fn~"'nru::.\