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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michap.1 Arthur Visconti
MIDDLE CURRENT SURNAME
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
100
B. HOW DID LAST MARRIAGE END? (3) f!1 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 09/ 25 / 2007
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? i'!YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CfTY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
09/25/2007 Lake County. Florida l'!l' 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
nowledge and belief that the information I provided is true an
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, tha th ~best of
as to my right to enter into the m sta .. /t
21. SIGNATURE OF GROOM~ ft;p
(/ E CURRE
23. SUBSCRIBED AND SWORN TO/A IRM D BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York tate 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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) John C. Masterson
TIME MONTH YEAR
SEAL SIGNATURE ~. DATE 10/15/2009
MAILING ADDRESS 1 0: 38 AM 1 0
"-t-I 20 Middle sh Rd. WappinQers Falls. NY 12590 PM
STREET CITYITOWN STATE ZIP
~~~R~~RT:J IO~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR o~ RELIGIOUS
DATE AND AT THE TIME AND / J AM '
PLACE INDICATED. ..,. ;OD. P ) () /:( 09 9 0 OTHER, SPECIFY
~~J>l~~~~~T K 13 IrrJ,J W.)17 h l 7,,1 TITLE 12~~
SIGNATURE~ }atJ{~ /~./ DATE /0 //7 /09
MAILING ADDRESS / ~ f':' II ~ I (/ 01 /
/5- (0 '1Zo vi e.... J 76 L/l/t::l,t' 'pJkJt r-" h:J.A./'/ III /. / ZS-? 0
STREET CITYrroWN'-1 7" ",' STATE
30. WITNESS T)l-,CEREMONY
NAME (PRINT) \J.... \ ~
COUNTY Dutchess
CITYITOWN Wappinger
~~~:kc: 1368 .
~~~I:J~R 121
1. A. FULL NAME
FIRST
0..
I'l
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)080 64 9818
D. SOCIAL SECURITY NUMBER ___ - _ - _ _
2. RESIDENCE A. FIB. La k e
(STATE) (COUNTY)
C. CHECK ONE olJ CITY 0 TOWN 0 VILLAGE
~~~CIFY Clermont
D. STREET ADDRESS 16214 Arrowhead Trail ZIP 34711
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES(] NO
OR /02 /1963
MONTH DAY YEAR
3. A. AGE 4R
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Physician
B. TYPE OF INDUSTRY OR BUSINESS Health Care
5. PLACE OF BIRTH New York NY
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME P::lsqlJalp. Visconti
B. COUNTRY OF BIRTH U S A
7. MOTHER
A. MAIDEN NAME June Ann Rydberg
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARFlIAGE 2
SIGNATURE~
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Annette Maria Leone
MIDDLE CURRENT SURNAME
.J
11. A FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Visconti
(OPTIONAL - SEE REVERSE.. 52-64-4886
D. SOCIAL SECURITY NUMBER I
12. RESIDENCE AFL B.Lake
(STArE) (COUNTY)
c. CHECK ONE "D CITY 0 TOWN 0 VILLAGE
~~~CIFYClermont
D. STREET ADDRESS16214 Arrowhead Trail
Z,P34711
o YES"D NO
7976
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE32 3B. DATE OF BIRTH 12 ,,3'1
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATIONReceptionist
B. TYPE OF INDUSTRY OR BUSINESS Health Care
15. PLACE OF BIRTHPoint Pleasant, NJ
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Nicholas Joseph Leone. Jr.
'B. COUNTRY OF BIRTJJ S A
17. MOTHER
A. MAIDEN NAME Clvdette Elizabeth Beck
B. COUNTRY OF BIRTJJ S A
18. NUMBER OF THIS MARRIAGE 1
t9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(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) (CITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
egal impediment exists
22. SIGNATURE OF BRID
by New York Domestic
MONTH
YEAR
16
2009
12
14 2009
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED h
A. STATE NEW YORK B. COUNTYYc;lC fSJ
C. LOCATION OF CEREMONY
(CHECK ON,\AND SPECIFY)
o CITY O~ TOWN OF 0 VILLAGE OF
SPECIFY W /l ej2/ here r-
If .)
ClD -iJ.
SIGNATURE~