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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
James Elijah Quilter
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYITOWN Wappinaer
~~~:~c: 1 368 '
~5~I:J~R4 7
1, A. FUll NAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
B, BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSEb97 68 3472
0, SOCIAL SECURITY NUMBER --
2, RESIDENCE A, NY B, Dutchess
(STATE) (COUNTY)
C, CHECK ONE D CI~ TOWN D VILLAGE
AND W .
SPECIFY applnger
o STREET ADDRESS 7 Canterbury Lane; Apt B ZIP 12590
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YEd'TI NO
3, A, AGE?7 3B, DATE OF BiRTH 04 /03 /1983
MONTH DAY YEAR
to-
:;;
4, EMPLOYMENT
A. USUAL OCCUPATION Consultant
B, TYPE OF INDUSTRY OR BUSINESS Professional Services
5, PLACE OF BIRTHGoshen. NY
(CITY, STATE I COUNTRY IF NOT USA)
6, FATHER
A NAME Richard Darrell Quilter
B, COUNTRY OF BIRTH USA
7, MOTHER
A, MAIDEN NAME Deborah Ann Stubecki
B, COUNTRY OF BIRTH U S A
8. NUMBER OF THIS MARRIAGE 1
9. ~~~~~~~RMtf~~W8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Nicole Renee Fusco
MIDDLE CURRENT SURNAME
.J
DEATH
o
B. HOW DID lAST MARRIAGE END? (3) D DIVORCE
C, DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
11, A, FULL NAME
FIRST
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) (CITYICOUNTY, STATElCOUNTRY,IF NOT USA) SELF SPOUSE
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGEQuilter
(OPTIONAL - SEE REVERS'577 -13-6093
0, SOCIAL SECURITY NUMBER
12, RESIDENCE ~Y put chess
(STATE) (COUNTY)
C. CHECK ONE D CITY"1:J TOWN D VILLAGE
AND W .
SPECIFY aP7.lnger
0, STREET ADORES Canterbury Lane; Apt B
Z,p12590
D YES....D NO
)-981
YEAR
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE?
13. A. AG~8 3B, DATE OF BIRTH 07 )'2
MONTH DAY
14. EMPLOYMENT
A. USUAL occuPATlo~ocial Worker
B, TYPE OF INDUSTRY OR BUSINESsMental Health
15. PLACE OF BIRT~lattsburgh, NY
(CITY, STATE I COUNTRY IF NOT USA)
16, FATHER
A, NAMENicholas Fusco
'B, COUNTRY OF BIRTM S A
17, MOTHER
A, MAIDEN NAME Deborah Ellen Kardel
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
DEATH
o
(3) D ANNULMENT (2) D DEATH
/ /
,'- YEAR
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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, cepose and. y,
as to my right to enter into the ar
D 1ST
D 2ND
D 3RD
D 4TH
d belief that the information I provided is tr e a
D D
D D
D D
D D
gal impediment exists
U
23, SUBSCRIBED AND SWO N TOI FFIRMED BEFORE ME
SIGNATURE OF TOWN R CI CLERK ~
This license authorizes e marriage in New Y rk 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.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremon .
~ 24, TOWN OR CITY CLERK 25, A, SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Jo C. Masterson
TIME MONTH YEAR
SEAL SIGNATURE~ DATE 05/07/2010
MAILING ADDREl;lS 11:49 AM 05
'-v-I 20 Middle ush Rd. WappinQers Falls, NY 12590 PM
STREET CITYITOWN STATE ZIP
~~~R~~RTr~~ 'o~O!#.~N:.zl~ 26, SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME 0, AY YEAR 0 M'RELlGIOUS
DATE AND AT THE TIME AND./J(fIft ~
PLACE INDICATED, 3 ',0 0 PM 9 D OTHER, SPECIFY
22. SIGNATURE OF BRIDE~
DATE 05/07/201 0
by New York Domestic
MONTH
YEAR
08
2010
06 2010
07
28, PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY ()rr.J-R.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~~~
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SIGNATURE
MAILING ADD
J9-.cITY OF D TOWN OF D VILLAGE OF
SPECIFY }/'e-I,'..,"~ v..-rl
, .,
SIGNATURE~