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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~c~ 1368 .
~5~I:J~R 95
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mir.h~p.1 Anthon" M~n7o
MIDDLE J CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL V)
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Dena Marie Giannelli
MIDDLE CURRENT SURNAME
.-J
1. A FULL NAME
11. A. FULL NAME
FIRST
FIRST
ll.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE M~n7o
(OPTIONAL - SEE REVERSE)122 74 1 088
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 11 F Canterbury Lane
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 131 74 5130
D. SOCIAL SECURITY NUMBER _ _ _ - __ - _ _ __
2. RESIDENCE A. NY B. f)l Jtr.hp.~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 11 F Canterbury Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
3. A. AGE ?Fi 3B. DATE OF BiRTH 11 / O~ / 1 ~R3
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE?
13. A. AGE 24 3B. DATE OF BIRTH 09 /f 4
MONTH DAY
ZIP 12590
o YES~ NO
;(984
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Video Editor
B TYPE OF INDUSTRY OR BUSINESS Television Media Arts
5. PLACE OF BIRTH Poughkeepsie. NY
(CITY. STATE I COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Retail
B. TYPE OF INDUSTRY OR BUSINESS Build A Bear Workshop
15. PLACE OF BIRTH Yonkers. NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Denis James Giannelli
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Mariorie Marie Allen
B. COUNTRY OF BIRTHU S A
18. NUMBER OF TH'IS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
6. FATHER
A. NAME Paul Manzo
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Linda Marie Laffin
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
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) (CITY/COUNTY, 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, PROVIOE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
o
o
o
o
o
o
1ST
2ND
3RD
o
o
o
21. SIGNATURE OF GROOM~
23. SUBSCRIBED AND SWORN TO/AFFIRME
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
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
0" 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) Joh C. Masterson
TIME MONTH YEAR
SEAL SIGNATURE ~. DATE 08/28/2009
'- .-J MAI\..!fiG f.~PldRE,~eS AM
-v- LU M al sh Rd. WappinQers Falls, NY 12590 02:26PM 08
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27~TY OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND J AM / I
PLACE INDICATED. ~;O J 0 og 01 90 OTHER. SPECIFY
~~~tf~~~~TR~v, Fr, ~c.(rt\e..s L,P fl1lctf'q TITLE i<.,C. fC',e.s-t-
SIGNATURE~:U ~ ~/'), ~\ {).~~DATE (JJe:>f-.. iJ ~ Odor
b~NGADDR s. ,g-:t-i-h s~>.::- A/. r.: ' I 04s-g
STREET CITY OWN STATE ZIP
SO. WITNESS TO CEREMONY 31. WITNESS TO CEREMON
NAME (PRINT) {ri r, ~.e phr:t c+
DATE
by New York Domestic
MONTH
YEAR
10
27 2009
29
2009
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~7C4 c. ff
C. LOCATION OF CEREMONY
(CHECK ONE AN)! SPECIFY)
o CITY OF rn'TOWN OF 0 VILLAGE OF
SIGNATURE ~