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COUNTY Dutchess
CITYrrow}J wappinger
DISTRICT 'I ;:Se8
NUMBER
REGISTER ( (
NUMBER
tcorrected by clerk
9/09/09
JCM
:SlATE UF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Anthony Joseph Cioli
MIDDLE CURRENT SURNAME
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1 . A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL, SEE REVERSE)11 0-66-5220
D SOCIAL SECU(l,rr)' NUMBER
2 RESIDENCE A. NY B. Dutchess
(STATE).L (COUNTY)
C. CHECK ON~ . . D. CITY U TOWN 0 VILLAGE
~~~CIFY vvapplnger
014 Blackthorn Loop
D. STREET ADDRESS ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED ~rGE? tP
3. A. AGE 26 3B. DATE OF BIRTH / 0
MONTH DAY
12590
'"
Y/ f9~03
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Electrician
Local 3
B. TYPE OF INDU:>JR~pR BUSI/llj:SS
5. PLACE OF BIRTH ::;urrern, NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER J h Ph'j' C' I'
A NAME 0 n lip 10 I
. USA
B. COUNTRY OF BIRTH
7. MOTHER Ad I'd D A r
A. MAIDEN NAME eual e e nge IS
~A
B. COUNTRY OF BIRTH I
B. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV'(fCE CIVIL AN5ULMENT
DE6TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
L Kl SUPPLEMENTAL FILE
FROM THE BRIDE
Christina Nicole Geisler
-1
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), t~IF1TRENT
C. SURNAME AFTER MARRIAGE 0
(OPTIONAL, SEE REVERSE)12 0- 70-1206
D. SOCIAL SW NUMBER uutcness
12. RESIDENCE A. B.
(STATE) ~ (COUNTY)
C. CHECK O~ .D CITY , TOWN 0 VILLAGE
AND t"'ougnKeep e
SPECIFY . 9 RorHli~ La[J~ 12590
D. STREET ADDRESS ZIP
.,
E. IS RE~D4NCE WITHIN LIMITS OF CITY OR INCORPORATC~VILLAGEJ9 0 YjS8~O
13. A. AGE 3B. DATE OF BIRTH --
MONTH DAY YEAR
14. EMPLOYMENT 0 t I A . t t
en a SSIS an
A. USUAL OCCUPATION Dr. Gross & Flores
B TYPE OF IND~TRY OR fflFeNEf.S
15. PLACE OF BIRTH ronXVI, y
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER R Id W'II' G' I
ona I lam els er
A. NAME USA
B. COUNTRY OF BIRTH
17. MOTHER. Catherine Ann Connolly
A. MAIDEN NAME U 5' A
B. COUNTRY OF BIRTH 1
lB. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D'ljORCE CIVIL A~ULMENT
D~TH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- . YEAR
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
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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
3RD
4TH
I duly swear/affirm, depose and say, th
as to my right to enter into the marn
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
ge and belief that the information I provided is true a
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22. SIGNATURE OF BRIDE ~
21. SIGNATURE OF GROOM~
23. SUBSCRIBED AND SWORN TO/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
RBlatiDns 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 CITJ8hiEl~, Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) ~if:- ~
P.-f 07/22/2009
SEAL SIGNATURE" L, ~ DATE
'-.,;-I MA'2~MR.MJe sh Rd, Wappingers Falls, NY 12590
STREET ZIP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER,
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
7/22/2009
by New. York Domestic'
YEAR
09
2B. PLACEWHERE MARRIAGE OCC~
* ~
A. STATE NEW YORK B. COUNTY' '
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) * .
~ WapP1nger
~-eF- 00.. TOJili, O~. ~ 0 VILLAGE or
~dO..~'t! .
SPECIFY' -...!
STATEOF~
COUNTY OF tu~YeSS
Affidavit for
Correction of Marriage Record
FOR OFFICIAL NYS USE ONLY
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
} SS:
\e\
]I We, -A'l\\'r\Of\;), (\0 \"\
room)
being severally sworn, depose and say that:
and
-.J 3.
Date of Marriage:
~ - \ S -
('
(Street Address)
lA.) 0.. ~ ~ '\ 'Clef <0
09
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fJ.Y.
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r1.
We reside at:
I
y.. 2.
Marriage License issued by City[rown:
4. Error(s) appearing on record (list exactly):
. ~
a.\.1 JOWU'L8 O~ --\;--n l} Q....a.->
b.
c.
5. Correct information as it should appear (list exactly):
a. ;:::lo~ o~ \^- )a-w~
b.
c.
6.
c.
This affidavit with supporting documentation is being made for, the purpose of having the record of marriage show the
true facts and this affidavit will become a permanent record. The marr" e record is fil with e State of New York.
~...
Signature of Husband 0' 0 A \)
.~... (> j~ ~~~J;vv
Signature of Wife .
Subscribed and sworn to q .
(affirmed) before me this day of ~\p m '\€(
NDta~ Public ~1L( (!!11lf[ ill
NOTE: Certificate of Authenticity required for notary public outside New York State
MICHELLE CHIUMENTO
No.01CH6165603
Notary Public. State of New York
Qualified In DutchessEl~~~ III
My Commission Expires ~
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(OVAr\
Reverend Sara Henderson-Ingeman
Interfaith Minister
141 Valley Farm Road
Millbrook. NY 12545
August 29. 2009
Town Clerk
20 Middlebush Road
Wappinger Falls, NY 12590
Town Clerk:
At your request I am sending you this letter requesting a change be made as follows for
the Marriage license of Anthony Joseph Cioli & Christina Nicole Geilser who I joined in
marriage on August 15, 2009. Please change my "Incorrect entry" on Block #28 from
Wappinger Falls to Town of Wappinger.
I am sending your affidavit onto Anthony & Christina to complete the remainder of your
requests.
Reverend Sara Henderson-Ingeman
Interfaith Minister
141 Valley Farm Road
Millbrook, NY 12545
September 1, 2009
Dear Anthony & Christina,
Again I apologize for the inconvenience. Attached is an Affidavit for the Correction of
Marriage Record. Please fill in the areas where I have marked with an "x".
Take to a notary of the public where you must signature the bottom where it says
"Signature of Husband, Signature of wife" in the presence of the notary.
Take all the pages enclosed to the Wappinger town clerk.
My best to you both!
Rev Sara
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