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COUNTY Dlltchess
CITYrrOWN W::Ippingp.r
~~~:~c~ 1 368 .
~~~~J~R 7!i
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
DonaJ~l4oseph R*ern-RE~VSURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL V)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
A~D~~la Draoo CURRENT SURNAME
-1
1. A. FUll NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 0~-RR-40?Q
2. RESIDENCE A. NYSTATE) B. ~!~uCZRr!=:!=:
C. CHECK ONE 0 CITYIl] TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 1012 Jefferson Blvd ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YESIII\':::] NO
3. A. AGE 43 3B. DATE OF BIRTH "7 / 15 / 1 ~RR
MOliliH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Rein
(OPTIONAL - SEE REVERSEI. 02 56 0030
D. SOCIAL SECURITY NUMBER I - -
12. RESIDENCE ANY B.Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY.c TOWN 0 VilLAGE
~~~cIFYFishkill
D. STREET ADDREss1 012 Jefferson Blvd
ZIP 12524
DYES "'0 NO
)966
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE?
13. A. AGE44 13B.DATE OF BIRTH 06 ,.2'4
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Operator W\NTP
B. TYPE OF INDUSTRY OR BUSINESS Waste Water
5. PLACE OF BIRTH 91~~S~A7E~ t:O~~RY IF NOT USA)
6. FATHER
A. NAME Donald loseph Rein ~r
B. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A. MAIDEN NAME r.::Irnlp. Fmily Olsen
B. COUNTRY OF BIRTH I J ~ A
8. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATIONReceptionist
B. TYPE OF INDUSTRY OR BUSINESsMedical
15. PLACE OF BIRTHWhite Plains, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEAngelo Drago
'B. COUNTRY OF BIRT~taly
17, MOTHER
A. MAIDEN NAME Concetta Fischetti
B. COUNTRY OF BIRT~taly
1 B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (g), 0 DEATH
C. DATE LAST MARRIAGE ENDED? 07 / 28 / 20u4
MONTtIIo DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? Ll 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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
10/?Q/?OOQ Westchester, Ny ~ 0 1ST 07/28/2004 Poughkeepsie, Ny 0 ~
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
wledge and belief that the information I provided is t ediment exists
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) i!l DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 10/ 29 / 2009
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say
as to my right to enter into the marr
W
en
z
W
o
::i
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.
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) J~. Masterson
{SEAL SIGNATURE ~ C:. .~ DATE 06/30/2010 TIME MONTH YEAR MONTH DAY YEAR
MAILING ADDRESS AM 01 2010 08 29 2010
'-.t-I 20 Middlebush Rd, Wappinoers Falls. NY 12590 03:15PM 07
STREET CITYITOWN STATE ZIP
~~~R~~~RT~~J 'o~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY I
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 1 ~ CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED.
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~\..&.,
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY Po~ '^Lu"f' \c..
TITLE ':I \J..-nc..t.
.
NAME (PRINT)
SIGNATURE~ ·
DOH-98 (09/2009)
SIGNATURE~