137
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Nir.h~I&!Lk W~mm fUg!~NV~~RNAME
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law !i11to 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) John C. Masterson
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE 10/05/201
'-- -.J MAIIJ.~ ~QC>I.FjE:=\Se AM
--yo- :':::U M cm sh Rd, Wappingers Falls, NY 12590 02:58PM 10
CITYITOWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 1 ~VIL
4-:a,AM
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~f; 1368 .
~E~I~~~R 1 37
1. A. FULL NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 532-90-3604
2. RESIDENCE A. NY B. nlltr.hp.~s
1ST ATE) (couNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND P hk .
SPECIFY 0119 p.p.psle
D. STREET ADDRESS 567 Sheafe Rd: Lot 32 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES tJ NO
3. A. AGE 28 3B. DATE OF BIRTH Mol~ / DQ) / yl~81
4. EMPLOYMENT
A. USUAL OCCUPATION Corredinn~ Offir.p.r
B. TYPE OF INDUSTRY OR BUSINESS Corrections
5. PLACE OF BIRTH Fort Lewis., Washington
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME I Inknnwn
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Katherine E Foldvik
B. COUNTRY OF BIRTH LJ S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
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(2) 0 DEATH
(3) 0 ANNULMENT
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
YEAR
MONTH OA Y
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
I"
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Christina Jeanne Nolen
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Fnlrl vi k
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 058-64-6442
12. RESIDENCE A. NY B. Dutr:hess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY I!i"l TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
D. STREETADDREss567 Sheafe Rd: Lot 32 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES l"'l NO
/15 /f964
DAY YEAR
13. A. AGE 46
04
MONTH
13B.DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Bartender
B. TYPE OF INDUSTRY OR BUSINESS Restaurant
15. PLACE OF BIRTH Carmel. New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Gene A Nolen Sr
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Nancy A. Moccio
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
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 (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 08 / 02 / 1996
MONTH DAY'- YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO
DEATH
o
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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
08/02/1996 Wake County, NC ~
1ST
2ND
3RD
4TH
that the information I provided is
MONTH
YEAR
06
2010
12
04 2010
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
o CITY OF 0 TOWN OF c(';,ILLAGE OF
SPECIFY COLt) Spa-,f..-I,
NAME (PRINT)
SIGNATURE~