060
+
w
~
C")Ul
C"')
L()
N
.....
~
!z>- :>
~Z c(
~....; e
...J Ow u.
8,"u.
~=~c(
is Q)i
f:: :1:0
~ Q) t::
!i; ~
ffiIo
a:
w
~
if
a:
~
u.
o
~
o
ii:
~
w
()
w
a:
w
i
m
m
w
a:
c
c
<(
~
l3
w
ll.
m
+
~~~ W
2jEf::
~,,~ ~
fj;~~ oc(
::>ow
::l1<!l5 ~
!z~Cll -
~~~ t:
tEem w
~~~ 0
l!!~",
o~z
z:;_
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c~1368
~5~1:~~R60
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Christopher William Jay
MIDDLE CURRENT SURNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Melissa Domenica Peterson
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
ll.
N
4. EMPLOYMENT
A. USUAL OCCUPATION Army
B. TYPE OF INDUSTRY OR BUSINESS Military
5. PLACE OF BIRTHAbington, Pa
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Charles William Jay
B. COUNTRY OF BIRTH USA
B. BIRTH NAME (MAIDEN NAME)JF DIFFERENT
C. SURNAME AFTER MARRIAGE ay
(OPTIONAL - SEE REVERSI{)88-76-7886
D. SOCIAL S~C;V~ NUMBER
NY uutcness
12. RESIDENCE A. B.
(STATE) ~ (COUNTY)
C. CHEC~E t...D 1i~T.'(1 D TOWN D VILLAGE
AND as t-IS lKII
SPECI 85 C I D
aro r
D. STAEET ADDRESS ZIP
E. IS R~IDENCE WITHIN LIMITS OF CITY DR INCORPORA~ VILLAGE~ D
13. A. AGEf: 1 3B. DATE OF BIRTH ~
MONTH DAY
14. EMPLOYMENT M h d"
A. USUAL OCCUPATloN'~erc an ISing
Home Depot
B. TYPE OF IND~TRY OR ilU::iI~ESS
15. PLACE OF BIRTH\"armel. NY
(CITY, STATE / COUNTRY IF NOT USA)
16, FATHER .
A. NAMEEnc A. p~t~r~on
B. COUNTRY OF BIRTH
.,
Y}98~O
YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE188_7 0-4801
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. OK B. Comanche
(S~ AJE) (COUNTY)
C. CHECK ONE "[] CITY D TOWN D VILLAGE
~~~CIFY Lawton
D. STREET ADDRESS 5309 B au Rd ZIP f3bU3
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES D NO
3. A. AGE21 3B. DATE OF BiRTH 05 /07 . /1989
MONTH DAY YEAR
12533
7. MOTHER
17. MOTHER
Donna M. Settembrini
A. MAIDEN NAME
U::SA
B. COUNTRY OF BIRTH I
18. NUMBER OF THIS MARRIAGE
A. MAIDEN NAME Cathleen Marie Max
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
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DffORCE CIVIL A~ULMENT
DttTH
D"(1TH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT (2) D DEATH
/ /
- YEAR
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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
rr.'
w
~
:::>
z
c
z
<(
Iii
w
~
1ST D 0 1ST D D
2ND D D 2ND D D
3RD D D 3RD D D
4TH D D 4TH D D
I duly swear/affirm, cep'ose 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 lage state. _ .#,,~
21. SIGNATURE OF GROOM" . ""' 22.SIGNATUREOFBRIDE"~~~~ ~ I
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEF RE ,J;E_-. ~ n USE C RENT NAME 06/07/2010
SIGNATURE OF TOWN OR CITY CLERK ~ ,.,f'-/-"" DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
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 ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) John C. Masterson
{SEAL SIGNATURE ~ DATE 06/07/201 0 TIME MONTH YEAR MONTH
'- -.J MA~~lt1fcfM sh Rd, Wappingers Falls, NY 12590 AM 06 08 2010 08 06 2010
-v- 03:00pM
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME M. DAY YEAR 0 D RELIGIOUS 1 V'CIVIL
~t;~E ~~gIC~~;~E TIME AND '1- 9 D OTHER, SPECIFY
w
en
z
w
o
::;
YEAR
29. OFFICIANT
NAME (PRINT)
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 1( ..l ~ it IJ lS
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF ~TOWN OF D VILLAGE OF
SPECIFY I 1) a /) /I " K..../J y:> r
b 11 J
SIGNATURE~
DOH-98 (0312006)