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COUNTY DLltchess
CITYrrOWN Wappinger
~~~~~c; 1368 .
~~~~~~R 1 03
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thqm~ Paul FQ!]ilH SURNAME
I
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Nitj!bt Di\~m Mi~~~ENTSURNAME
.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
c. sVS~~1A~~~~t~~~~~s~ orcelli
D. SOCIAL SECURITY NUMBER 1 ??-7 4-?~~R
12. RESIDENCE A. N~STATE) B. D~b$5iS
C. CHECK ONE 0 CITY Ql TOWN 0 VILLAGE
~~~CIFY WaprinOF>r
D. STREET ADDRESs41 Tnr Rn~rl ZIP 12fi90
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 33 3B. DATE OF BIRTH~TH ~ ~AY ..1.~l~
14. EMPLOYMENT
A. USUAL OCCUPATION Sales Associate
B. TYPE OF INDUSTRY OR BUSINESS Rp.t~il
15. PLACE OF BIRTH ~~~T~%~~~r;},QRY ~roT USA)
16. FATHER
.A. NAME John Henry Miller
B. COUNTRY OF BIRTH I J S A
17. MOTHER
A. MAIDEN NAME np.ni!=:p. Rit~ Shp.rn!=:h
B. COUNTRY OF BIRTH I J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 134-724190
2. RESIDENCE A. NV B. n. '+I"'hess
(STATE) ~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND \M .
SPECIFY Iilpplnger
o STREET ADDRESS 41 Tor Rn::ld ZIP 1?!1qn
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
MOJrQ / 011 / y1j73
3. -A. AGE 35
4. EMPLOYMENT
3B. DATE OF BIRTH
A USUAL OCCUPATION Self Employed
B. TYPE OF INDUSTRY OR BUSINESS Fitness
5. PLACE OF BIRTH 't.R~~ATI/~b~;rv IF NOT USA)
6. FATHER
A. NAME john Forcelli, Sr.
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Katherine ~~inichino
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
DEATH
n
DEATH
o
(2) 0 DEATH
Q
o
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH OA Y
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH OA Y 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) (CITYICOUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
W
U)
Z
W
o
::::;
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swellr/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my nght to enter Into the ma lage state., I
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF BRIDE~ \-.. "v":A '~Cl.'S<L () \.....-\ '- lL ~
USE R USE CURRENT NAME .
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME DATE 09/08/2009
SIGNATURE OF TOWN OR CITY CLERK ~ ----------
This license authorizes the marriage in New' Yo State of the bride and groom named above by any person authorized by New York Domestic
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 onl for the purpose of a second or subsequent ceremony,
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-.t-'
NAME (PRINT)
YEAR
YEAR
MONTH
TIME
MONTH
AM
12:24PM
09
09
2009
11
07 2009
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED. ~
29. OFFICIANT
NAME (PRINT)
SIGNATURE~ /J;
M IL G~!\SSS
/(6.S'-
STREET
30. WITNESS TO ~~ONY .....-""
:::::::: (?~~~~: tb .-
l~IVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYh ((I-f.1te!JS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF It(..TOWN OF 0 VILLAGE OF
SPECIFY !1Jt1-f.:}qArr~