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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
G\';tYoLrral1Z LanJl!AA~T SURNAME
COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~CRT 1 368 .
~5~';J~R 11 0
1. A. FULL NAME
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 ~ 1-n4- 70? 1
2. RESIDENCE A. '" 1sT ATE) B. Qc~~rtl E' c;: S
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY W~rringArs F::ills
D. STREET ADDRESS 23 Market StZlP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY DR INCORPORATED VILLAGE? fil'1 YES 0 NO
3. A. AGE 40 3B. DATE OF BIRTH nR / n" / 1969
MORTA DA I' YEAR
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
4. EMPLOYMENT
A. USUAL OCCUPATION Flnorino I nst~II;:ltinn
B. TYPE OF INDUSTRY OR BUSINESS Flooring Installation
5. PLACE OF BIRTH MOl mt \lernon New York .
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Fr::m7.1 I ~noPn
B. COUNTRY OF BIRTH France
7. MOTHER
A. MAIDEN NAME N::inr.y Ruth DeVeaux
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
o 0
DEATH
o
(2) 0 DEATH
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.1::inA M~riA r.tlrAt
MIDDLE CURRENT SURNAME
~
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT G i a m pi ~~ol 0
C. SURNAME AFTER MARRIAGE I (;InOAn-r.llrAt
(OPTIONAL - SEE REVERSE)090 58 3155
D. SOCIAL SECURITY NUMBER ___ - __ - _ _ __
12. RESIDENCE A. NY B. nt ltr.hASS
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFYWappingers Falls
D,STREET ADDRESs23 Market St ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A. AGE ~R 3B. DATE OF BIRTH 04 /511 A971
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Nurse
B. TYPE OF INDUSTRY OR BUSINESS NY DOC
15. PLACE OF BIRTH Yonkers New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME .John ~iampiccolo
'B. COUNTRY OF BIRTHltaly
17. MOTHER
. A. MAIDEN NAME Rose Ann Bloomer
B. COUNTRY OF BIRTHU SA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
100
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 04 / 02 / 1998
MONTH DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? i!l'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
04/02/1998 Westchester. New York 1'!'1
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1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~H 0 0 ~H
I dUly swear/affirm. dep.ose and say, that to the best of my knowledge and belief that the inform
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM ~ 22. SIG ATURE OF BRIDE ~
US 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 authorized by New York Domestic
Relations Law ~11 to pertorm 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
{ SEAL SIGNATURE~ ~ ~ ~ DATE 09/18/2009 TIME MONTH YEAR MONTH YEAR
MAILING ADDRESS )~sh 10:03AM 09 17 2009
"-v-I STR~W Middleb sh Rd. Wapg~~~rs Falls'sT~! 1259~p PM 19 200911
~~~R~~~RTr~J 'o~O~~~N~Zl~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY 28. PLACE WHERE MARRIAGE OCCURRED
SONS NAMED ABOVE ON THE T ME MO. DAY YEAR 0 ~LIGIOUS 1 0 CIVIL D 7t. '"
DATE AND AT THE TIME AND AM A. STATE NEW YORK B. COUNTY 14 C t"U
W PLACE INDICATED. , I !bO 10 / r 9 0 OTHER, SPECIFY
~ ~~~t~~~~~T /J.o('~t.e' C;;'fe- TITLE
~ SIGNATURE~ /fnntL ~
i= MAILING ADDRESS
a: 7- ON f . . (J.lIA.i'(H 12,..~4ttuleG
w STREET CITYrrOWN
(.) 30. WITNESS TO CEREMONY
NAME (PRINT) :J e.~S\c.. ~ ~. L .e..~~ .r
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YEAR
SIGNATURE~
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DATE 09/18/2009
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY WaPflA./fUT Pi II J
, J
NAME (PRINT)
SIGNATURE~