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COUNTY nlltr.hA!;!;
CITYfTOWN Wappinger
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~5~I:J~R 1 01
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
DiI~~le DiGena)(iNT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
K(;ltherinp Alyr.p F::lrmpr /
MIDDG" CURRENT SURNAME
~
, . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
..
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. sVS~~:~M~~~~t~WC~~sRiGeno\la
D. SOCIAL SECURITY NUMBER 043-72-1435
12. RESIDENCE A. NY B. nlltr.hpc::c::
(STATE) (COUNlY)
C. CHECK ONE 0 CITY lZl TOWN 0 VILLAGE
~~~CIFY Fa!;t Fishkill
D STREET ADDRESS 1 Sebastian Court
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 4R3-4fl-OQ? 1
2 RESIDENCE A. NXTATE) B. 11cy!~ess
c. CHECK ONE 0 CITY eJ TOWN 0 VILLAGE
~~~CIFY F::lc::t Fic::hkill
o STREET ADDRESS 1 Seba!;tian Court ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 't'J NO
3. A. AGE 30 3B. DATE OF BIRTH MO~ /~) / Y~
4. EMPLOYMENT
A. USUAL OCCUPATION EnginE'er
B. TYPE OF INDUSTRY OR BUSINESS I R M
5. PLACE OF BIRTH ~~:g;::;~o~~rvJ N~)(JsrA)(::t!;
6. FATHER
A. NAME Merio ~"ichelE' f1iGE'nn\le
B. COUNTRY OF BIRTH Italy
7. MOTHER
A. MAIDEN NAME Olimpi::t C':::tmp::tgna
B. COUNTRY OF BIRTH It::tly
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
ZIP 12533
o YES~ NO
/f'QR1
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 28 3B. DATE OF BIRTH n? A 1
MONTH DAY
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COLI.
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14. EMPLOYMENT
A. USUAL OCCUPATION FnoinAAr
B. TYPE OF INDUSTRY OR BUSINESS Computers
15. PLACE OF BIRTH Manchester, Conn
(CITY. STATE / COUNTRY IF NO;r USA)
16. FATHER
A. NAME C':h::lrIAC:: Frlw::trrl F::trQ1Ar
. B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Carol Ann Olsen
B. COUNTRY OF BIRTHU S A
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
DEATH
n
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) (CllY/COUNlY, 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
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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 swe!lr/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true al)d that I declare that no legal impediment exists
as to my right to enter Into the marnage,st~e. 1/ r
21. SIGNATURE OF GROOM~ >>M~ 0, tC~ ..' 22. SIGNATURE OF BRIDE~ A.-4::i..J.'v.1lAA-L' ~}~
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ~~E CUR "PIT NAME USE CURRENT ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE 09/04/2009
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 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
,-I'-.,
{ SEAL}
'-v-I
25. B. SOLEMNIZATION PERIOD
ENOS AT MIDNIGHT ON:
NAME (PRINT)
DAY
YEAR
TIME
MONTH
YEAR
MONTH
DATE 09/04/2009
ers F lis NY 12590
WN STATE ZIP
27. TYPE OF CEREMONY
o ~IOUS
9 0 OTHER, SPECIFY
11 :08AM 09
PM
05
200911
03 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.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~ ~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~N OF 0 VILLAGE OF
SPECIFY ~I ;?;'J;e;t.L
10 CIVIL
TITLEC~L~ t.- ~/t'sr
DATE JO./5"/ "2c.v'f
I 2- ~3 ~
IV.~
STATE
NAME (PRINT)
SIGNATURE~