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1 . A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST MatthEt'MD~Y<:ln r,i::l'Pu~ntr~AME
I
I
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~; 1368 .
~~~I~~~R 143
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Rritt;:tnv Alltumn DuPont
Mil'iDlE CURRENT SURNAME
~
11. A. FUll NAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 ? A-7 4-fl439
2. RESIDENCE A. NXTATE) B. 9c~~t<mess
c. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY ::IpplngAr
D. STREET ADDRESS 16 MacFarlane Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 1l"l NO
3. A. AGE 22 3B. DATE OF BIRTH MO~ / oW / Yt~87
4. EMPLOYMENT
A. USUAL OCCUPATION IInemp10yed
B. TYPE OF INDUSTRY OR BUSINESS LJnemployed
5. PLACE OF BIRTH POIlohkAAn~iA J Nv
(CITY, S'flITE / COU;rrRY IF NOT iJ!lA)
6. FATHER
A. NAME Marc William GiamlTl8tteo
B. COUNTRY OF BIRTH LJ S A
7. MOTHER
A. MAIDEN NAME I oriA .JA;:tn Hoffm;:tn
B. COUNTRY OF BIRTH I J S A
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE r,i::lmm::lttAo
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 116-75-6751
12. RESIDENCE A. NY B. DlltchA~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 16 Macfarlane Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
/~O A991
DAY YEAR
13. A. AGE 1q
13B.DATE OF BIRTH
OR
MONTH
~
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c(
c
wU:::
u.
-c(
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS Unemployed
15. PLACE OF BIRTH Pouahkeeosie, Nv
(CITY, STATE / COUmRY IF NOT irsA)
16. FATHER
A. NAME Don;:tld DuPont
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Corinne Rose
B. COUNTRY OF BIRTH USA
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
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
'"
2E
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o 1ST
o 2ND
o 3RD
o 4TH
elief that the information I provided is tru
1ST 0
2ND 0
3RD 0
4TH 0
I duly swear/affirm, depose and say, that to the best of my knowledge and
as to my right to enter into the mar la e s te.
21, SIGNATURE OF GROOM~
USE C
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Yo
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
{ } NAME (PRINT) Jo C. Mast rson
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE 10/08/201
~ MAI~cr ~~dale ush Rd. WappinQers Falls. NY 12590 AM 10
STREET CITYITOWN STATE ZIP 04:02PM
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER. _ ./
SONS NAMED ABOVE ON THE T ME MO. DAY YEAR 0 0 1 LJ;CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED.
22. SIGNATURE OF BRIDE ~
DATE
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
09
2010
12
07 2010
~')
28. PLACE WHERE MARRIAGE OCCUR~ \ {
A. STATE NEW YORK B. COUNTY .12" i(.,W~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF
SPECIFY ~
NAME (PRINT)
SIGNATURE ~
DOH.98 (09/2009)
NAME (PRINT)
SIGNATURE~