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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert C Fraser
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYITOWN Wappinger
DISTRICT1368 '
NUMBER
REGISTER 134
NUMBER
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE062_64_2390
D. SOCIAl. SECURITY NUMBER
2. RESIDENCE A. NY B. Westchester
(STATE) J? (COUNTY)
C. CHECK ONE 0 CITY TOWN 0 VILLAGE
~~CIFY Greenburg
D. STREET ADDRESS 15 Blrchwood Lane ZIP 1 uo3u
ol
E. IS RESIDENCE WITHIN LIMITS OF CIlY OR INCORPORATED VILLAGE? 0 YES P. NO
3. A. AGE 29 3B. DATE OF BIRTH 03 /01 /1980
MONTH DA V VEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Chef
B. TYPE OF INDUSTRY OR BUSI"I.E!)S Hospitality
5. PLACE OF BIRTH Yonkers, NY
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME William G. Fraser
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Helen p, Cacciatore
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANBULMENT
DEOTH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATI1
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAV
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) (CITYICOUNTV, STATElCOUNTRV, IF NOT USA) SELF SPOUSE
YEAR
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
"I
Lo
~
SUPPLEMENTAL FILE
FROM THE BRIDE
Dana Marie Galbo
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME),~ OIFFERENT
C. SURNAME AFTER MARRIAGE raser
(OPTIONAL - SEE REVERSE{)69-70-13oo
D. SOCIAL sr;,CIl.RJTY NUMBER
NY uutcness
12. RESIDENCE A. B.
(STATE) ol (COUNTY)
C. CHECK QbLE hk,[J CITY 0 TOWN 0 VILLAGE
AND rlS III
SPECIFY 4 10 I Rldgecrest Dr 12590
D. STREET ADDRESS ZIP
.,
E. IS RE~~NCE WITHIN UMITS OF CITY OR INCORPORA!f~VILLAGE??7 0 YE~M~O
13. A. AGE 3B. DATE OF BIRTH L E
MONTH DA V VEAR
14. EMPLOYMENT Chef
A. USUAL OCCUPATION Hos Ita lit
B. TYPE OF IND~TRY OR ~INESS P Y
15. PLACE OF BIRTH ronx, y
(CITY. STATE I COUNTRY IF NOT USA)
18. FATHER W'II' C Ib
A NAME I lam a 0
. USA
B. COUNTRY OF BIRTH
17. MOTHER
Rose Siciliano
A. MAIDEN NAME LJ S A
B. COUNTRY OF BIRTH I
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D~ORCE CIVIL A~ULMENT
D'tlTH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,-.~ YEAR
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) (CITYICOUNTV. STATElCOUNTAV, IF NOT USA) SELF SPOUSE
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
best of my knowledge and belief that the information I provided is tr
o 0
o 0
o 0
o 0
impediment exists
NAME 11/23/2009
DATE
by New York Domestic
MONTH
YEAR
a
USE CU
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person auth rized
Relations Law ~11 to perform marriage ceremonies within NBW York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license Is to be used onl for the purpose of a second or subsequent ceremony,
r-I'-. 24. TOWN OR CITY C ERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Jo
11/23/2009 TIME MONTH YEAR
SEAL SIGNATURE ~ TE
MAI~ AAPd81 appi ge s Y 12590 AM 11 24 2009
'-v-' 03:33pM
STREET CITYITOWN ZIP
~~~R~~RT~~ ~~O~~N~:~ 26. SOLEMNIZATION OCCURRED
SONS NAMED ABOVE ON THE TIME Y YEAR 0 iiI:..flELIGIOUS
OATE AND AT THE TIME AND AM
W PLACE INDICATED. .I!.lo I OJ... lO 90 OTHER, SPECIFY
~ ,~,f~~~"U4J!1> G...Afb/",{\., TInE (' .--....u '- r>>/U tZ It
SIGNATURE~ DATr;jJ~~~ 0
i= MAILlN~DDRESS R ^ _ Jt":2 ....L. _ ~ . ' / '\
rx /7.-' fr> A (,H.~ t N'G. 1'4r-V ol.. ~ '::L " ~
W _ -STREET. -.. -GIT'r'ITOWN . 'STATE-- -
(,) 30. WITNESS TO CEREMONY
01
22 2010
28. PLACE WHERE MARRIAGE OCCURRED
NAME (PRINT)
SIGNATURE~
10 CIVIL
A. STATE NEW YORK B. COUNTY f!:::,t?d~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
OkelTY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY N €uS 'to -a 'e.
SIGNATURE~ ,