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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thn'J;h~L~ .ln~F!ph ~~~iSURNAME
1ST D D 1ST
2ND D D 2ND
3RD D D 3RD
4TH D D 4TH
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is t
as to my right to enter into th~a~ stat~. ~. ,_
21. SIGNATURE OF GROOM ~ 2 SIGNATURE OF BRIDE ~
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.
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) Jo C. Masterson
TIME MONTH YEAR
SEAL SIGNATURE. DATE 07/12/201
MAILING f.~9FjE~S 10:40AM 07
'-v-' 20 Mloole ush Rd, Wappingers Falls, NY 12590 PM
STREET CITYITOWN STATE ZIP
~~~R~~~Ri~~~ IO~O!r~~N~EE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0"" RELIGIOUS
DATE AND AT THE TIME AND AM (}'4J
PLACE INDICATED. 5~ "I'i' PM ., '2-Jf ~o, \) 9 D OTHER, SPECIFY
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~~ 1368 .
~~~liJ~R 79
1 . A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 097 -70-3834
2. RESIDENCE A. NY B. n. Jtr.hF!~~
(STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 152 Robinson Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
1 n / 11 /1977
MONTH DAY YEAR
3. A. AGE 32
3B. DATE OF BIRTH
t-
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u.
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4. EMPLOYMENT
A. USUAL OCCUPATION Rllilning~ Ann Grounds
B. TYPE OF INDUSTRY OR BUSINESS Hackley School
5. PLACE OF BIRTH Yonkers, NY
(CITY, ST ATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Thnm::l~ .1F!ffF!ry Kaegi
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Judith lolonardi
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
n 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
a:
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STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Sta~~DL~arie Arv~~~RENT SURNAME
--.J
11. A. FUU NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Kaeg i
(OPTIONAL - SEE REVERSE)137 78 7312
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~~CIFY Wappinoer
D. STREET ADDRESS 152 Robinson Lane
ZIP 12590
D YES~ NO
A'970
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13, A. AGE 39 l3B.DATE OF BIRTH 10 A8
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Hackley School
15. PLACE OF BIRTH Trenton, NJ
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME John Arvelo
'B. COUNTRY OF BIRTHPuerto Rico
17. MOTHER
A. MAIDEN NAME Darlene Anderson
B. COUNTRY OF BIRTHU 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
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
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
o 0
D 0
D 0
o 0
are that no legal impediment exists
29 OFFICIANT 1""'~~" _A\ ~ ::-;-,-..rl
NAME (PRINT) "t:.,VJ V'l.:::> . .:;;;, . """v\. TITLE -rA-s:: (u ~
SIGNATURE. _ _ DATE D7r~r(D
MAILING ADDRESS r-.. ~ Fl J::>. n - - '-P
50\ E::G ~r~ ~ ~~-S'f"t"JI\J(~ to, 'O~
STREET CITYfTOWN STATE ZIP
30. WITNESS TO R'REMONY 1/ 31. WITNESS TO CEREMO Y
NAME (PRINT) t;; (" $ f!.,., NAME (PRINT)
SIGNATURE.
DOH-98 (09/2009)
by New York Domestic
MONTH
YEAR
13
2010
09
10 2010
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYJ)j,l~ C~ sS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY O'lJ5 TOWN OF D VILLAGE OF
SPECIFY E..., -F\S t"'hL'tt.L
SIGNATURE.