068
+
o
Q')
L{)
N~
...-;5
en
>='
Z
~C/) I-
zro :;
lllLL <(
lll~ Q
~Q)w u::
~c~u.
u>.- <(
~rol
~~~
a 0
ll!-c
wro
~o
~o::
~Q)
...=
0'-
t!:!>
-<c
~h:
~c
wro
~.c
fEU.
~,....~
lZ ~
W z
a: 0
g ~
-< tii
~ ~
@ ~
Q.
U>
w
en
z
w
0
::i
+
~t~ W
~~i= I-
a:><;S <(
~~~ 0
::lOW
::ECl5 u::
!z3;U> i=
~~~ a:
[0(1) w
o~> 0
..w~
l!!~",
OW
zg3;
COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~~ 1368 .
~~~:~~R68
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
~
1. A. FULL NAME
n~le Rohert M~sse~
MIDDLE CURR NT SURNAME
FROM THE BRIDE
Terri L~nn Rath
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFEREN..8alvagin
C. SURNAME AFTER MARRIAGERath-Massey
(OPTIONAL - SEE REVERSQh72 60 0897
D. SOCIAL SECURITY NUMBER U - -
12. RESIDENCE ,NY BPutchess
(STATE) (COUNTY)
C. CHECK ONE 0 ClrvYb TOWN 0 VILLAGE
AND D hk .
SPECIf'l4_ ouo eepsle
D. STREET ADDRES71 Hampton Road
11. A. FULL NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSEb94 54 3202
D. SOCIAL SECURITY NUMBER --- - --- ----
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITWtJ TOWN 0 VILLAGE
~~CIFY poughkeepsie
D. STREET ADDRESS 1 Channinoville Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? otJ YES 0 NO
Ofi /17 /1958
MONTH DAY YEAR
Z,P12603
o YES""D NO
~66
YEAR
3. A. AGEfi?
3B. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGe44 3B. DATE OF BIRTH 01 ;(3
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATlo~ortoaae Rep
B. TYPE OF INDUSTRY OR BUSINES~ankinQ
15. PLACE OF BIRTJ\L!orristown, New Jersey
(CITY, STATE / COUNTRY IF NOT USA)
4. EMPLOYMENT
A. USUAL OCCUPATION M~intenance
B. TYPE OF INDUSTRY OR BUSINESS Government
5. PLACE OF BIRTHEort Walton Beach. Florida
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Rohert Henry Massey
B. COUNTRY OF BIRTH U S A
7. MOTHER
A. MAIDEN NAME Joyce Mae Townsend
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARF,lIAGE 2
16. FATHER
A. NAM~aul H. Salvagin
. B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAMEDorothY A. Whalen
B. COUNTRY OF BIRT~ S A
1B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT DEATH
1 0 0 1 0 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) '6 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 08 / 19 / 1988 c. DATE LAST MARRIAGE ENDED? 07 / 1 0 / 2008
MONTH DAY YEAR MONlIjo DAY' ~. - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? i!!r YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? l"J YES 0 NO
~
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 08/19/1988 Poughkeepsie. Ny ~ 0 1ST 07/10/2008 PouQhkeepsie, Ny 0 '6
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affinn, depose and s:lrl2hat 0 the best of knowledge and belief that the Information I provided is true diment exists
as to my right to enter into the mrjge tate.
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF BRIDE~
USEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Yor State of the bride and groom named above by any person authorized
Relations Law ~11 to perfonn 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. Ma~
{ SEAL SIGNATURE~ a! r:1~ DATE 06/22/2010 TIME MONTH YEAR
MAILING ADDRES~ AM
'-v-I 20 Middleoush Rd. Wappinoers Falls. NY 12590 01 :05 PM 06 23 2010
STREET CITY/TOWN STATE ZIP
~~~R~~Ri~~~ 10~O~~~N~:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 VI CIVIL
DATE AND AT THE TIME AND f'l
PLACE INDICATED. 9 0 OTHER, SPECIFY
DATE
by New York Domestic
MONTH
YEAR
08
21 2010
29. OFFICIANT
NAME (PRINT)
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY W~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ Vj'JAGE OF
SPECIFY ~tLdJIr
NAME (PRINT)
SIGNATURE~