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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Mark AnJI~D?Env Scepp~~~;;~~~~ME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c;1368
~~~~;~R45
1. A. FULL NAME
..
N
B. BIRTH NAME. IF DIFFERENT
(Inl\:) ;:,r.MI..fC rvn .:t/MIC V;.:>C U/VL.II
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Giuseppina Antonina Spatola
FIRST MIDDLE CURRENT SURNAME
.-l
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE},.,66 68 9075
D. SOCIAL SECURITY NUMBERU - -
2 RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY..o TOWN D VILLAGE
~~~CIFY WappinQer
D. STREET ADDRESS 15 G Alpine Dr ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES~ NO
12 /21 /1981
MONTH DAY YEAR
3. A. AGE 27
3B. DATE OF BIRTH
11. A. FULL NAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEb93_78_0056
D. SOCIAL SECURITY NUMBER
12 RESIDENCE ANY BDutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY '6 TOWN D VILLAGE
D. :~:~; :=~fkn~e~'Plne Dr
ZIP 12590
D YES~ NO
)'985
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Auto Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Auto
5. PLACE OF BIRTH Yonkers, New York
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Mario Frank Sceppaquercia
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Theresa Mary Ricciardi
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
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE24 3B. DATE OF BIRTH 05 )1'1
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INOUSTRY OR BUSINESS Education
15. PLACE OF BIRTHQueens, New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Salvatore Spatola
'B. COUNTRY OF BIRT~taly
17. MOTHER
A. MAIDEN NAME Giuseppa Vilardi
B. COUNTRY OF BIRT~taly
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
(3) D ANNULMENT
/ /
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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) (CITYICOUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
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C. DATE LAST MARRIAGE ENDED?
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
4TH
I duly swear/affirm, depose and say, th
as to my right to enter into the marn
21. SIGNATURE OF GROOM ~
D D 1ST
D D 2ND
D D 3RD
D D 4TH
est of my knowledge and belief that the information I provided is true and that I declare
by New York Domestic
25. B. SOLEMNIZATION PEAIOD
ENDS AT MIDNIGHT ON:
MONTH
YEAR
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If 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) Jo ,
{ OS/20/2009 TIME MONTH YEAR
SEAL SIGNATURE ~
MAI.kIONG.AP.I.o~Ei~S Y 12590 AM 05 21 2009
'-v-I STR~ET Mlaall ZIP 12: 13 PM
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DAY
07
19 2009
STATE
27. TYPE OF CEREMONY
o ~ELlGIOUS
9 D OTHER, SPECIFY
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ]I.... +&h<~.5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF ~WN OF D VILLAGE OF
TITLE {().Jt,o/,'" fX7',5+
DATE 10/7 /OCf
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N~
STA E
AM
M
29. OFFICIANT Ro ~ ~ .
""" I'ffi"" bt~T . "~
SIGNATURE~ ~ B,
MAILING ADD RES
103 J~vK:Sbl'1 5'+. 80x L ~ ;J., K',' II
STREET CITYfTOWN
30. WITNESS TO
(,
1
o
NAME (PRIN
SPECIFY (,'s~Jt..1I
NAME (PRINT)
SIGNATURE ~