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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c: 1368
~~~I:~~R 73
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Shaun Michael Giammichele
MIDDLE CURRENT SURNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Erin Anne Schriffen
MIDDLE CURRENT SURNAME
.-J
1 . A. FULL NAME
11. A. FUll NAME
FIRST
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Giammichele
(OPTIONAL - SEE REVERSE084_64_7059
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(STATE)..L (COUNTY)
C. CHECK ON!; .0 CITY U TOWN 0 VilLAGE
~~~CIFYFlshklll
D. STREET ADDRESS' U Chase Ur
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)131_72_7575
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY'tJ TOWN 0 VilLAGE
~~~CIFY East Fishkill
o STREET ADDRESS 53 Verplank Ave ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
04 /17 /1979
DAY YEAR
1 LbL4
ZIP
3. A. AGE 30
3B. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE?
13. A. AGE28 3B. DATE OF BIRTH 07 )1'5
01..
o YES 0 NO
)980
YEAR
MONTH
MONTH
DAY
4. EMPLOYMENT
A. USUAL OCCUPATION EnQineer
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH Mt Kisco, Ny
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME John Anthony Giammichele
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary Paula Schwarz
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
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDU~TRY OR ~~SIN..f.iSS Education
15. PLACE OF BIRTHKockvllle L;entre, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEGary Thomas Schriffen
B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Roseanne Butler
B. COUNTRY OF BIRTHU S A
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DOORCE CIVIL A'5'ULMENT
DEATH
o
D~TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(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
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm. depose and say, that to the best of my knowledge and belief that the information I provided is~rue d that I declare
as to my right to enter Into the marrrag state,
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF BRIDE~ .
USE CU
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
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 Clj CLE~K 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)
YEAR
SEAL SIGNATURE ~
~ MA~tl'~F.l
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND 3
W PLACE INDICATED. PM
5 ~,.\'I'[~~1I;1j:e ~~~s S;~~t/~ mce P e h4''-
!:!: SIGNAT'~E~~~..{nL- DATE 7 41/;';.(/~r~.(}t09
I- MAILlNG~ESS '
a:w cS;-"/ip/~slf#",.? ~f(p(J#(/t?(i// //.5~A/tf-S //Wy #'#t;/?".NGE A/Y //7/d"'-fQC;yC
STREET CITYPfoWN '7 STArr 21P
o 30. WITNESS TO CEREMONY ("l 31. WITNESS TO C~MONY
NAME (PRINT) ..~ '" ~ L c.)(1 ',f I /;q Ai NAME (PRINT) VI"J
o 0
o 0
o 0
o 0
t no legal impediment exists
by New York Domestic
w
CJ)
Z
W
o
::J
YEAR
09
12 2009
2B. PLACE WHERE MARRIAGE OCCURRED
,
10 CIVIC
A. STATE NEW YORK B. COUN~VPfi7~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY 0' '!imw{; 0 '''CAGE 0' )
SPECIFY/SL/rJ #/!(//PtI(/~
SIGNATURE~