089
COUNTY Dutchess
CITY/TOWN Wappinger
~~J:~c; 1368 .
~5~I:J~R 89
Annotated by affidavit
/09/200
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Philip VincAnt SAttembrino
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Andrea Michele Koman
MIDDLE CURRENT SURNAME
-.J
1. A FULL NAME
11. A FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 067 60 4947
D. SOCIAL SECURITY NUMBER ___ - __ - __
2. RESIDENCE A. NY B. Putnam
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWND VILLAGE
~~~CIFY Carmel
D. STREET ADDRESS 408 Drew Lane ZIP 10512
E. IS RESIDENCE WITHIN L1t4ITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
3. A AGE ~? 3B. DATE OF BIR~C/Il o,~ / 17 /1977
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Settembrino
(OPTIONAL. SEE REVERSE)055 64 6661
D. SOCIAL SECURITY NUMBER --
12 RESIDENCE A. NY . B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE . 0 CITY ~ TOWN 0 VILLAGE'
~~~CIFY Wappinqer
D. STREET ADDREss21 0 Carnaby Street
ZIP 12590
DYES '6 NO
A978
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A AGE 30 3B. DATE OF BIRTH 09 /11
MONTH DAY
4. EMPLOYMENT
14. EMPLOYMENT
A USUAL OCCUPATION Administrative Assistant ". .
B. TYPE OF INDUSTRY OR BUSINESS Trinity-PawlinQ School
15. PLACE OF BIRTH Cold SprinQ, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A NAME Thomas Edward Koman
. B. COUNTRYOf BIRTHU S A
17, MOTHER
A. MAIDEN NAME Patricia Lee Kvart
B. COUNTRY OF BIRTHU S A
18. NUM~ER O~ T~lIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
A. USUAL OCCUPATION Self Employed
B. TYPE OF INDUSTRY OR BUSINESS Financial Services
5. PLACE OF BIRTH White Plains. New York
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME John Settembrino
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Marietta Lagana
B. COUNTRY OF BIRTH U . 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
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. STATElCOUNTRY, 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
1ST
2ND
3AD
4TH
I duly swear/affirm, depose and
as to my right to enter int
21. SIGNATURE OF GROOM~
o 1ST 0 0
o ~D 0 0
o 3RD 0 0
o 4TH 0 0
elief that the information I provided is true and that I declare that no legal impediment exists
IGNATUREOFBRIDE~~ ~~.
USE CURRENT NAME
D~TE 08/19/2009
23. SUBSCRIBED AND SWORN TO/AFFIRM
SIGNATURE OF TOWN OR CITY CLER
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.
o If checked, this license is to be used only for the urpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
by New York Domestic
~
{ } NAME (PRINT)
SEAL SIGNATURE ~ 08/19/2009
10.- .-J MAI!.lI1G /lQPI
-v- LU IVI in ers Fal s, NY 12590
STREET CITYrrOWN STATE ZIP
~~iRJ:RT~~~ 'o~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. AY YEAR 0 ~ RELIGIOUS
DATE AND AT THE TIME AND ..AM /J_
PLACE INDICATED. r::;.'Je PM P1IJCt, ~9. .:LGO'j 90 OTHER, SPECIFY
29. OFFICIAN~.J/' ." -11 ~. J ./ I V ~.. : -::)_ -..." fi ,....~~ /....
NAME (PRINT) ~'- ..",) c..,... "" ~ TITLE ~""'7^' <.A;,,--...Ie. ,..J
SIGNATURE ' p.e. ~ DATE ~. c.Z~. ~y
MAILING A9pR .. ./ -;J.-;)
III' C.EJ:7/#!,- I~/(~.(C"Y .c1tJ., /'O(,)c.,IM:e:CP"sIC./ /'/.)! /..2~(j::;
STREET CITY/TOWN STATE
30. WITNESS T~EMONY 1:B
NAME (PRINT) L _ . _ bf ( ^ CI
SIGNATURE~
YEAR
MONTH
YEAR
TIME
MONTH
AM 8
03:20PM 0
20
2009
10
18 2009 .
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTYJJ/J7~-S~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY ~ TOWN OF .0 VILLAGE OF
SPECIFY~ ~ 0 G> Ii .c ec,t::JS/~
10 CIVIL
NAME (PRINT)
31. WITNESS T
SIGNATURE~
,
, ..
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Affidavit for
Correction of Marria e Record
FOR OFFICIAL NYS USE ONLY
Erin Taback-Galbrat h
Notary Public State File #
Groom:
01TA6123946 Bride:
NYS EXP 5-21-2013 Date Completed:
We, PHi LIP V I we f. NT 5 E1rE M B (2.1 '" 0 and AND fl.€: A t-Il, ~ HE I.. E ~ 0 MAN
(Groom) (Bride/Maiden Name) .
being severally sworn, depose and say that
STATE OF
COUNTY OF
} 55:
1 . We reside at
408 DREW LAtJf;
t.. A f<. "" E" 1- I N Y
105'"12-
2.
Marriage License issued by Cityrrown:
Date of Marriage: 08 I 2- 9 (
(Street Address)
\IV A P P I tV G- Ef<-
2.009
(State)
(Zip Code)
3.
4. Error(s) appearing on record (list exactly):
a. GJ2.00M'S DA,~ OF Blf<.T1-!
0-=1- , ,-=l- r 19"1- =r
b.
c.
5. Correct information as it should appear (list exactly):
a.
Gf2.00M' 5
DAlE 0 F B' t2- 11-\
01 (1-=t-1'9:f-::t-
b.
c.
6. Documentation Submitted:
a.
G (2..00 M 's C,Ei:(l." F' cArlE: 0 F Blfz/14 REG-I STl<.A 11 0 ""
b.
c.
This affidavit with supporting documentation is being made for the purpose of having the record of marriage show the
true laoW and this affidavit will become a pennanen! record~ T~~;:b N=~
Signatu of Husband
~~1--~~
y /-{ Signature of Wife
day of
-
Notary Public ~ ---
Subscribed and sworn to
(affirmed) before me this
NOTE: Certificate of Authenticity required for notary public outside New York State
n/"'lu -1 QI')'7 tnl::/l')nnJl\
(over)
~QJLQQjjJ~mJmillQQJL~
New York State Department of Health 11
Albany, N. Y. 12237 .~
QIertificate of ~ irtq ~eBistration ~
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New York II
oooor.
This certifies that a certificate of birth has been filed under the name of:
PHILIP VINCENT SETTEMBRINO
Sex:
Male
Born on:
January 17, 1977
At:
White Plains
, New York
Name of father:
John Se t temb rino
Maiden name of mother:
Marietta Lagana
Date filed:
Local Registration No.: 60
January 24, 1977
Date issued:
January 26, 1977
Re strar of Vital Statistics
Address: White Plains,
This notice is void if it contains any erasures or corrections.