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COUNTY Dutchess
CITYfTOWN Wappinger
DISTRICT1368
NUMBER
REGISTER 156
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Justin Paul Ferreira
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Brandie Marie Stacey
MIDDLE CURRENT SURNAME
--1
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Stacey-Ferreira
(OPTIONAL - SEe REVERSEl()72-72-0988
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(STATE) ~ (COUNTY)
C. CHECK ONE [J CITY L,J TOWN 0 VILLAGE
~~~CIFY PoughKeepsie
D. STREET ADDRESS 1 Oakwood Drive
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE29 13B.DATE OF BIRTH 07 ~O
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEU79_74_2627
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY"6 TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 1 Oakwood Drive
ZIP 12090
DYES "6 NO
)'981
YEAR
3. A. AGE31
ZIP 12590
YES ~ NO
/1979
YEAR
MONTH
DAY
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
09 / 07
MONTH DAY
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Electrician
B. TYPE OF INDUSTRY OR BUSINESS Constructiorl
5. PLACE OF BIRTH Bronx, NY
(CITY, STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION School Psychologist
B. TYPE OF INDUSTRY OR BUSINESS Eaucation
15. PLACE OF BIRTH Poughkeepsie, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard P. Stacey
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Dawn Ellen Kane
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
6. FATHER
A. NAME Frank Ferreira
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Rosemarie Theresa Andriach
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
o 0
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D50RCE CIVIL A~ULMENT
Dl1TH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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
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 arnage e. ~ ~
21. SIGNATURE OF GROOM~ . 22. SIGNATURE OF BRIDE~
o 0
o 0
o 0
o 0
I impediment exists
ME
11/12/2010
DATE
by New York Domestic
I This license authorizes the marriage in New ork 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.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY qLERK,.... M t 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) JOnn l,;, as erson
{SEAL SIGNATURE ~ DATE 11/12/2010 TIME MONTH YEAR
'-v-' MA~(fIOOI(M~ ush Rd, Wappingers Falls, NY 12590 03:24 ~~ 11 13 2010
STREET STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE 0 0 RELIGIOUS
DATE AND AT THE TIME
PLACE INDICATED. 9 0 OTHER, SPECIFY
25. B. SOLEMNIZATION PERIOD
ENOS AT MIDNIGHT ON:
MONTH
DAY
YEAR
01
11 2011
l~VIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B.COUNTY"i}_rc.~
C. LOCATION OF CEREMONY
(CHECK ONE AN~ECIFY)
o CITY OF [l('TOWN OF 0 VILLAGE OF
SPECIFY t.V~p(A)b..tL
NAME (PRINT)
SIGNATURE~
DOH-98 10912009)
NAME (PRINT)
SIGNATURE~