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1 . A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Jonattliu Dominic cMMlr?i>~NAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Yi
"I
COUNTY nl Itr.he~~
CITYrrOWN W;:tppinger
~~~~:f: 1 ~RR .
~5~;~~R RO
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
K ridi~lIfol~nAA PAt~b~~~ SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~1A~~~rEA~~C~~s~azz~
D. SOCIAL SECURITY NUMBER 053-70-5086
12. RESIDENCE A.NY B. nlltr.he~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY oiZJ TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 1 B Van Cortland Circle
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER OR~-7R-~Rn4
2. RESIDENCE A. NXTATE) B. ~c~E'SS
C. CHECK ONE 0 CITY olZI TOWN 0 VILLAGE
~~~CIFY Fi~hkill
D STREET ADDRESS 1 B Van Cortland Circle ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
MO~TQ / ~l / y1iBi
ZIP 12508
o YES~ NO
/f' ~R4
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE ?4 3B. DATE OF BIRTH 11 /?O
MONTH DAY
3. A. AGE 27
4. EMPLOYMENT
A. USUAL OCCUPATION \^,::liter
B. TYPE OF INDUSTRY OR BUSINESS Bllgaboo Creek
5. PLACE OF BIRTH POI l~hkeAg~ie ~
(CITY. S ATE I cou TRY IF NOT SA)
6. FATHER
A. NAME Dominir. P M::l77::l
B. COUNTRY OF BIRTH Italy
7. MOTHER
A. MAIDEN NAME Karen I Secchi;:t
B. COUNTRY OF BIRTH L J S A
6. NUMBER OF THIS MARRIAGE 1
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Information Specialist
B. TYPE OF INDUSTRY OR BUSINESS Hvfcu .
15. PLACE OF BIRTH Pouahkeepsie Nv
(CITY, ~ATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Herbert John Peterson'
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Kimberly Ann Richner
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
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
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. ~ YEAR
B, HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
1ST
2ND
3RD
o
o
o
o
o
o
o 0
o 0
o 0
o 0
impediment exists
USE
23. SUBSCRIBED AND SWORN T 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 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 supsequent ceremony.
,-.^-.. 24 TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGiNS
} NAME (PRINT) J 0 .
{ ~ ~
SEAL SIGNATURE ~' - ATE 07/29/2009
MAILING ADDRESS 10 43AM
'-v-I 20 Middl Rd Wa i ersFalls NY 12590 : 07 30 200909 27 2009
STREET CITY/TOWN STATE ZIP PM
~~~R~~RT~~~ ~~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 [\.CIVIL
DATE AND AT THE TIME AND AM ~ ,
PLACE INDICATED. S':~ 0 PM D ~~ 0 9 0 OTHER, SPECIFY
~~~lf~~~~T~_ - _ _'l':,+uhe" TIn-' ::-Jid~
SIGNATURE~_ ~ DATE ~l.;t~ oC1..
MAILING Aftr.SS . t \\
)R~ET fe r- . CI~W~ f f'. (A c; STh{ Y I J. ~~
30. WITNESS TO CEREMONY 31. WITNESS TLREMONY
NAME (PRINT) NAME (PRINT) ~
:kx-
DATE
07/29/2009
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY Diht"~ f
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF I'SI TOWN OF 0 VILLAGE OF
SPEciFY \\loop \AJ W i ~ d SOr
SIGNATURE~
DOH-98 C0312OD61
.....
SIGNATURE~