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COUNTY 01 Jtr:hA~~
CITYfTOWN W::IppingAr
~~J:f: 1 :\RR .
~5~I~J~R 1 4~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jo1i<;;hael Nas~JRRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
MegaOID~~een Ha"1;mQMuRNAME
-.J
1 . A. FUll NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 067 -66-2269
2. RESIDENCE A. N);TATE) B. Q~ess
C. CHECK ONE 0 CITY 0 TOWN oIlI VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 73 So 11th RAm~An Avp.: Apt ZIP 1 ?~~n
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? i'ii!f YES 0 NO
3. A. AGE 35 3B. DATE OF BIRTH MOCl~ / D~1 / y1j75
4. EMPLOYMENT
A. USUAL OCCUPATION Traffic Control
B. TYPE OF INDUSTRY OR BUSINESS Transportation
5. PLACE OF BIRTH ~~~R~toD!~y IF NOT USA)
6. FATHER
A. NAME Raymond Jos8ph Nass
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME loyce Marie Mccormack
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. s~S~:~Mr;:r~~~t~~~As~ass
D. SOCIAL SECURITY NUMBER R 1 ~-:\R-4:\??
12. RESIDENCE A. N'(STATE) B. D('e'~ss
C. CHECK ONE 0 CITY 0 TOWN I!iil' VILLAGE
~~~CIFY W::Ippinop.r~ F::III~
D. STREET ADDRESS 7:\ SOllth Remsen Ave; Apt ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A. AGE 27 13BDATEOFBIRTH---t1~H /1~y /'f~
14. EMPLOYMENT
A. USUAL OCCUPATION Execllti\le Assi~t::lnt
B. TYPE OF INDUSTRY OR BUSINESS Non-profit
15. PLACE OF BIRTH T::Iml mino r,11::Im
(CITY. STATE / ~~RY IF NOT USA)
16. FATHER
,A. NAME E'lgene Gordon Hcmmond
B. COUNTRY OF BIRTH l J S A
17. MOTHER
A. MAIDEN NAME .1::Ir.rJlIp.linA FilAAn M::I~tAr~on
B. COUNTRY OF BIRTH l J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
DEATH
n
o
o
o
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 (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (
MONTH DAY YEAR
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true an
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM.
o
o
o
o
o
o
w
en
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USE CU
23. ~::~fT~~~DO~Nfo~;~Oo~ J;~A~m~E~ BEFORE ME DATE 1 0/22/201 0
This license authorizes the marriage in New Yo the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wi in 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-'
NAME (PRINT)
TIME
MONTH
YEAR
MONTH
YEAR
AM
03:19PM
12
21 2010
10
23
2010
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
ITYIT N
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
A. STATE NEW YORK B. COUNTY bIJ'tCIU S S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
28. PLACE WHERE MARRIAGE OCCURRED
1~VIL
PM
10
2.1.(
b:'
TITLE MA-R./ltIA6e cx=t:' Cf:..i-
DATE~
)<
SPECIFY W APP I AJG l:: t...
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) Ma ~ Q a_oj
SIGNATURE~