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vv DEPARTMENT OF HEALTH
CITYrrOW}I applnger
~~~:~~rl::S0e. AFFIDAVIT, LICENSE and
~~~I:J~R 30 CERTIFICATE OF
*89~~Aw~ted by Affidavit MARRIAGE
FROM THE GROOM
Harry Francis Paolercio, Jr.
MIDDLE CURRENT SURNAME
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
-.J
FROM THE BRIDE
Anna Marie Martino
1 . A FUll NAME
11. A. FUll NAME
FIRST MIDDLE
Polochak
B. BIRTH NAME (MAIDEN NAME), ~DIFF~RENT
C. SURNAME AFTER MARRIAGE ao erclo
(OPTIONAL - SEE REVERSE)312-58-3176
D. SOCIAL s~r NUMBER
12. RESIDENCE A. B, uutchess
(STATE) "'- (COUNTY)
C. CHECK Oll!; Q CITY Q TOWN 0 VILLAGE
AND t"'ougl1KeepSle
SPECIFY 5 Stone Street
D. .STREET ADDRESS
CURRENT SURNAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)113-38-8325
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE).L (COUNTY)
C. CHECK DNi;... 0 CITY U . TOWN 0 VILLAGE
~~~CIFY t"'ougnkeepsle
D. STREET ADDRESS b ::>tone Street ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0
3. A. AGE 61 3B. DATE OF BIRTH 08 / 31
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Steamfitter
5. :~::~~:,~:Ur.J~\.$~g~~~TI~o~:~UyC~I~n
(CITY, STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT . .
A. USUAL OCCUPATION AdmInIS~~tor t
ucalon
B. TYPE OFINDLlEl,TflY QR.BUSINESS P I
vvasnlngtOn, ennsy vania
15. PLACE OF BIRTH
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A NAME Michael Polochak
. Ll SA
B. COUNTRY OF BIRTH
'12590
01
YES 0 NO
/1947
YEAR
.,
E. IS RE~rCE WITHIN LIMITS OF CITY OR INCOR:kORA!g4ILLAGE> 8 0 Y)-95~O
13. A. AGE 3B. DATE OF BIRTH 01
MONTH DAY YEAR
6. FATHER
A. NAME Harry Francis Paolercio
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Frances Razza
B. COUNTRY OF BIRTH USA
'L
8. NUMBER OF THIS MARRIAGE
17. MOTHER
Helen Louise Martino
A. MAIDEN NAME uSA
B. COUNTRY OF BIRTH 4
18. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVD,fCE CIVIL AN5ULMENT Dee,TH DI~ORCE CIVIL A~ULMENT D1jTH
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCO (3) 0 ~~LMENT 1 ~WEATH B. HOW DID LAST MARRIAGE END? (3) [j' DIVOR,~ (3) D~UlMENT 19~~ DEATH
C. DATE LAST MARRIAGE ENDED? 9 / / C. DATE LAST MARRIAGE ENDED? / /
MONT'Y" DAY YEAR MONT~ DAY' . - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH/ ,DA/Y1'9Ylieolll (CITY/COljNTY, STATI;ICOUlfTItY, IF NOT USA) SELF SPO~E ~Oj'Il,I;I,.pj\'y,~fJ\.B) M (CITY/COUNTY I , S!/lTElCOUNTRY. IF NOT USA) SELF SPO~E
1ST 09 22 '~f PoughKeepSie, NY 0 0 1ST UflL.L.r1'::JfO unCle, nalana 0 0
12/12/1988 Poughkeepsie, New York \I
2ND 0 0\ 2ND 12/13/1999 Poughkeepsie, New York 0 ~
3RD 0 0 3RD. 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, depDse and say, that to the best of my knowledge and belief that the information I provided is true 'mll dimenl exists
as to my right to enter into the mar I estate. f
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO/AFFIRMED B
SIGNATURE OF TOWN OR CITY CLERK"
This license authorizes the marriage in New York State of the bride and groom named above any person authorized by New York Domestic
W Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
tn 0 If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
Z ~ 24. TOWN OR. E C 25. A. SOLEMNIZATION PERIOD BEGINS
W { } NAME (PRINT) .
~ SEAL SIGNATURI!':. DATE 05/08/2009 TIME MONTH YEAR MONTH
'-v-I MAI~'tf ~bush Rd, Wappifigers Falls, NY 12590 03:10~~ 05 09 2009 07 07 2009
STREET STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER- V
SONS NAMED ABOVE ON THE 0 ~ELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~~Ae ~:5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF KTOWN OF 0 VILLAGE OF
SPECIFY -a ( 1 3 ~ k'~A~.PS I e...
TITLE -R ~ V
DATE 6 - ~ 1)- Of
t ~-/3
STATE
COUNTY Dutchess
CITYrrOW}l wappinger
DISTRICT'I3tRS
NUMBER
REGISTER 30
NUMBER
MAnnDta.tt
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
A: "hi:/. itCERTIFICATE OF
() A'" MARRIAGE
FROM THE GROOM
Harry Francis Paolercio, Jr.
MIDDLE CURRENT SURNAME
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVerCE CIVIL AN~ULMENT DE~TH DI~ORCE CIVIL A~ULMENT
~ ~
B. HOW DID LAST MARRIAGE END? (3) D DIVORCO (3) D ~~LMENT 1 ~WEATH B. HOW DID ~T MARRIAGE END? (3) D D1VOR~2 (3) D~ULMENT 19:9~ DEATH
C. DATE LAST MARRIAGE ENDED? 9 / / C. DATE LAST MARRIAGE ENDED? / /
MONTIV DAY YEAR MONTJV DAY, " ~ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
<-
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MOtlTH. DAY, Y~Bl (CITYICOl/NTY. STAn;tCOU~Yi IF NOT USA) SELF SPO~E ~0lI/D;!,.pj\1,~f/,/3) M (CITY/COUNT}'. sr/lTElCOUNTRY, IF NOT USA) SELF SPO~E
1ST 09/22/19t::11 PoughKeepSie, NY D D 1ST U/U.L.I'I'I:)IO unCle, Inalana D D
12/12/1988 Poughkeepsie, New York ~
2ND D D 2ND 12/13/1999 Poughkeepsie, New York D Qo
3RD D D 3RD D D
~ D D ~ D D
I duly swear/affirm, depose and say. that to the best of my knowledge and belief that the information I provided is true p diment exists
as to my right to enter into the mar I estate. t
. '"
21. SIGNATURE OF GROOM~
23. SUBSCRIBED AND SWORN TO/AFFIRMED B
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above 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.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR. E C 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) .
SEAL SIGNATUR~. DATE 05/08/2009 TIME MONTH YEAR MONTH
'-..t-I MAI~ ~bush Rd, Wappiilgers Falls, NY 12590 03: 1 O~~ 05 09 2009 07 07 2009
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER. V
SONS NAMED ABOVE ON THE TIME MO. DAY Y R 0 ~ELlGIOUS
~Cl6E~gIC-;"~E~E TIME AND wao 9 D OTHER,SPECIFY
TITLE -Re:J
DATE /; - ~ 1)- ()f
I ~"-3
FUll NAME
FIRST
9. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)113-38-8325
D. SOCIAL SECURITY NUMBER
RESIDENCE A. NY B. Dutchess
(STATE).L (COUNTY)
C. CHECK ONIi-. OkCITY U . TOWN D VILLAGE
~~~CIFY t-'ougn 'eepsle
D. STREET ADDRESS 0 :stone Street ZIP
E. IS RESIDENCE WllHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D
3. A. AGE 61 3B. DATE OF BIRTH 08 / 31
MONTH DAY
12590
YES ~ NO
/ 947
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Steamfitter
5. :~::~::I~:u~~~g~~~YI~~:~~c~l~n
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
....
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A. NAME Harry Francis Paolercio
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Frances Razza
B. COUNTRY OF BIRTIH USA
1.
8. NUMBER OF THIS MARRIAGE
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L 0 SUPPLEMENTAL FILE
-.J
FROM THE BRIDE
Anna Marie Martino
11. A. FULL NAME
FIRST MIDDLE
Polochak
B. BIRTH NAME (MAIDEN NAME), ~DIF;lRENT
C. SURNAME AFTER MARRIAGE ao erclo
(OPTIONAL - SEE REVERSE)312 -58-31 76
D. SOCIAL SEfIJ{l1JY NUMBER
12. RESIDENCE A. NY B. Uutcness
(STATE) "'- (COUNTY)
C. CHECK 00ll; .0 CITY Q TOWN D VILLAGE
AND t-'ougnKeepsle
SPECIFY 5 St et t l'llif'\n
one Q ree ,e,.";;:JU
D. STREET ADDRESS ZIP
E. IS RE!iIP,;,NCE WITHIN LIMITS OF CITY OR INCORPORA ~4VILLAGE? ::t 8 D
13. A. AGE01 3B. DATE OF BIRTH * U ~
MONTH DAY
14. EMPLOYMENT Ad' . t t
miniS ra or
A. USUAL OCCUPATION EA tl
uuca on
B.. TYPE OF IND4&.TRY Q8.BUSINESS P I I
ifVaSnlngton, ennsy van a
15. PLACE OF BIRTH
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER .
A NAME Michael Polochak
. uSA
B. COUNTRY OF BIRTH
17. MOTlHER
CURRENT SURNAME
~
YJ95~O
YEAR
Helen Louise Martino
A. MAIDEN NAME uSA
B. COUNTRY OF BIRTH 4
18. NUMBER OF THIS MARRIAGE
D1jTH
YEAR
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATIE NEW YORK B. COU~
C. LOCATION OF CEREMONY J J - 3
(CHECK ONE AND SPECIFY) OLD
D CITY OF :KTOWN OF D VILLAGE OF
SPECIFY fh ( J 0 ~k'~~e.o:'5 ) e..
v {
STATE OF New York
} 55:
~OF3 Affidavit for
Correction of Marriage Record
FOR OFFICIAL NYS USE ONLY
J-f ~/-1)9
erc.l
cu.-hi,
State File #
Groom:
Bride:
Date Completed:
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
COUNTY OF Dutchess
Harry Francis Paolercio, Jr.
(Groom)
being severally sworn, depose and say that
and
Anna Marie Polochak
(Bride/Maiden Name)
We,
2.
Marriage License issued by CityITown:
(Street Address)
Town of Wappinger
New Hamburg,NY 12590
(State) (Zip Code)
1.
We reside at
5 Stone Street
3. Date of Marriage:
June 20, 2009
4. Error(s) appearing on record (list exactly):
a. Bride - Date of Birth listed as 04/18/1952
b.
c.
5. Correct information as it should appear (list exactly):
Bride - Date of Birth should read 01/18/1952
a.
b.
c.
6. Documentation Submitted:
a.
Original Birth"'Certificate - with raised seal
b.
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 marriage record is filed with the State of New York.
CONNIE M. CARPENTER
Notary Public - State of New York
NO.01CA6154173
Qualified In Dutchess County.
My Commission Expires
~
~
Subscribed and sworn to d [ . I ~
(affirmed) before me this QT lI'-
day of :s-~----
~~
Notary Public ~~ ~
NOTE: Certificate of Authenticity required for notary public outside New York State
DOH-1827 (05/2004)
(over)
.....
_~IISTATE OF NEW YORK
.,.., DEPARTMENT OF HEALTH
Corning Tower
The Governor Nelson A. Rockefeller Empire State Plaza
Albany, New York 12237
Richard F. Daines, M.D.
Commissioner
Wendy E. Saunders
Executive Deputy Commissioner
August 7, 2009
JOHN C MASTERSON
TOWN CLERK
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS NY 12590
Groom:
Bride:
SFN:
HARRY FRANCIS PAOLERCIO JR
ANNA MARIE MARTINO
14421-2009M
Dear Town/City Clerk:
Enclosed is a copy of the marriage referred to by the above file in your office.
Correction to the original has been made based on:
I:8J Affidavit
D Officiant's Statement
D Signature on original marriage affidavit
D Statement verified by City/Town Clerk
D Other: Supplemental
HECE/VEU
AUG 1 3 2009
-,'1
~l1!~1 Gl..t=:n. ~
Please file this amended record along with the supporting documentation.
If you have any questions, please call us at (518) 474-2013.
Sincerely,
Linda Ortiz
New York State Dept. of Health
Vital Records Marriage Corrections Unit
P.O. Box 2602
Albany, NY 12220-2602
Enclosure
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
June 29, 2009
NYS Department of Health
Vital Records Section
Registration Unit
P.O. Box 2602
Albany, New York 12220-2602
Dear Mr. Carucci
SUPERVISOR
CHRISTOPHER J. COLSEY
TOWN COUNCIL
WILLIAM H. BEALE
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
Please fmd enclosed DOH-1827 -Affidavit for Correction of Marriage Record for
Harry Francis Paolercio Jr. and Anna Marie Martino and a copy of Anna Marie
Polochak's birth certificate which if have copied from the original.
Please contact me at my office, (845) 297-5771, if there are any problems.
Sincerely,
hn C. Masterson
own ClerklRegistrar of Vital Statistics
T own of Wappinger
STATEOF New York
Affidavit for
Correction of Marriage Record
FOR OFFICIAL NYS USE ONLY
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
} SS:
WHarry Francis Paolercio, Jr.
e,
(Groom)
being severally sworn, depose and say that
and
State File #
Groom:
Bride:
Date Completed:
Anna Marie Polochak
(Bride/Maiden Name)
COUNTY OF Dutchess
1.
We reside at
5 Stone Street
2.
Marriage License issued by Cityrrown:
(Street Address)
Town of Wappinger
New Hamburg,NY 12590
(State) (Zip Code)
3. Date of Marriage:
June 20, 2009
4. Error(s) appearing on record (list exactly):
a. Bride - Date of Birth listed as 04/18/1952
b.
c.
5. Correct information as it should appear (list exactly):
Bride - Date of Birth should read 01/18/1952
a.
b.
c.
6. Documentation Submitted:
a.
Original Birth'Certificate - with raised seal
b.
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 marriage record is filed with the State of New York.
CONNIE M. CARPENTER
Notary Public - State of New York
NO. 01 CA6154173
Qualified In Dutchess County
My Commission Expires
~
~
Subscribed and sworn to d lld:~~
(affirmed) before me this
day of :r~ <--
~~
Notary Public ~~ ~
NOTE: Certificate of Authenticity required for notary public outside New York State
1_. ._...\
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Affidavit for
Correction of Marriage Record
FOR OFFICIAL NYS USE ONLY
STATE OF New.York
} SS:
We,
Harry Francis Paolercio, Jr.
(Groom)
and
State File #
Groom:
Bride:
Date Completed:
Anna Marie Polochak
(Bride/Maiden Name)
COUNTY OF Dutchess
being severally sworn, depose and say that:
2.
Marriage License issued by Cityrrown:
(Street Address)
Town of Wappinger
New Hamburg,NY 12590
(State) (Zip Code)
1.
We reside at:
5 Stone Street
3. Date of Marriage:
June 20, 2009
4. Error(s) appearing on tecord (list exactly):
a. Bride - Date of Birth listed as 04/18/1952
b.
c.
5. Correct information as it should appear (list exactly):
Bride - Date of Birth should read 01/18/1952
a.
b.
c.
6. Documentation Submitted:
a.
Original Birth Certificate - with raised seal
b.
c.
This affidavit with supporting documentation is being made for the purp()se of having the record of marriage show the
true facts and this affidavit will become a permanent record. The marriage record is filed with the State of New York.
- - ~ --/ ~ 0 /2, _ .---'" /I
CONNIE M. CARPENTER .~ ~ 'l1
Notary Public. Stote of New York ~
, _. N~. 01eA6154173 . · Signalur f Husband /
~ Qualified In Dutchess County ~ ~( /J./. - /1./. / '-,---
My commlss~n EXPires LDIa..:t./IO ~~
- - _ tgnature of Wife '.
Subscribed and sworn to ~ C I j) -r
(affirmed) before me this r-,L ",,-;--"'-. Clay of .....J~ _ -- -- ~C}
Notary Public ~~ ~
NOTE: Certificate of Authenticity required for notary public outside New York State
nnl-L 1 R"7 /nl;/"nnll.\
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