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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~ 1368 .
~5~~J~R 7 2
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
r.~rmp.ln S~lldp.ri
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL V)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jennifer Lvnn Blakslee
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEb
D. SOCIAL SECURITY NUMBER 62 -64-7 440
2. RESIDENCE A. NY B. nlJt~hp.ss
(STATE) (COUNTY)
C. CHECK ONE 0 CITYolJ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 361 Route 82 ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YEs"'tJ NO
3. A. AGE 34 3B. DATE OF BiRTH n!1 / ?9 /1976
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION ()wnp.r ()pp.r~ter Pizza Restautant
B. TYPE OF INDUSTRY OR BUSINESS Entrepreneur
5. PLACE OF BIRTH Mount Vernon, Ny
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME S~lv~tnrp. ~iIISp.ppe S~uderi
B. COUNTRY OF BIRTH Italy
7. MOTHER
A. MAIDEN NAME Eugenia lebba
B. COUNTRY OF BIRTH Italy
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Scuderi
(OPTIONAL - SEE REVERSE), 17 66 3036
D. SOCIAL SECURITY NUMBER 'I - -
12 RESIDENCE ANY BPutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY..Q TOWN 0 VILLAGE
~~CIFYWappinQer
D. STREET ADDRES~61 Route 82
ZIp12533
o YES....O NO
;1'982
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGF27 3B. DATE OF BIRTH 11 ZO
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESsEducation
15. PLACE OF BIRTHPOuQhkeepsie, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEGary Fred Blakslee
'B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAME Pamela Mary VanWagenen
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
DEATH
o
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
..~ YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
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
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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, th
as to my right to enter into the marr
21. SIGNATURE OF GROOM. ~
o 1ST 0 0
o 2ND 0 0
o ~D 0 0
o 4TH 0 0
d belief that the information 1 provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE. n.JU~J.Q.)rt. ~
0- U USE CURRENT NAME
DATE 06/28/2010
~.
III
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by New York Domestic
USE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE 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
~
{ SEAL }
'-v-'
YEAR
MONTH
YEAR
TIME
MONTH
NAME (PRINT)
ATE 06/28/2010
in 'ers Falls NY 12590
CITYITOWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME M. DAY YEAR 0 lif RELIGIOUS
r /0 90 OTHER, SPECIFY
11 :21 AM 06
PM
SIGNATURE ~
MAILING ADDR
20 Mid I
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29
2010
08
27 2010
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B, COUNTY lJu'n:,.H~S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OFXTOWN OF J VILLAGE OF
SPECIFY cAS, ~ISH k'ILL.
SIGNATURE ~
MAILING ADDRE
4'1-17 ''oJ A
STREET
30. WITNESS TO
TITLE ASse(., l'04 STO~
DATE f.r - / T ~ /'0
YONi<@f.S NY (0 ?-O.s-
STATE ZIP
""""'" '" r
...,,,""" ~. ~ "'fbC<a
SIGNATURE~
NAME (PRINT)
SIGNATURE~