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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST PhilipM~~pnard Vir~Li~~E~[SURNAME
COUNTY Dutchess
CITYfTOWN Wappinqer
~~J~~c; 1368 .
~~~'~~~R27
1. A. FULL NAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)1 04 74 6797
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY..o TOWN 0 VILLAGE
AND W .
SPECIFY applnger
o STREET ADDRESS 48 Scarborouqh Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"tJ NO
3. A. AGE ?7 3B. DATE OF BIRTH 09 / 05 /1981
MONTH OA Y YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION It
B. TYPE OF INDUSTRY OR BUSINESS Technoloav
5. PLACE OF BIRTH Yonkers. NY
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Philip Leonard Virga
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Yolanda Juliana Biro
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
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
YEAR
MONTH DAY
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL V)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Janet Marie Indiviqlio
MIDDLE CURRENT SURNAME
~
11. A. FULLNAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Viraa
(OPTIONAL - SEE REVERSEb55_66_9140
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY '6 TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDREss48 Scarborough Lane
ZIP 12590
DYES '6 NO
;t'981
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE27 3B. DATE OF BIRTH 09 ~1
MONTH DAY
14. EMPLOYMENIT
A. USUAL OCCUPATION Paraleqal
B. TYPE OF INDUSTRY OR BUSINESS Law
15. PLACE OF BIRTH Bronxville I NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Ravmond Joseph IndiviQlio
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Carol DiPuma
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
(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
~
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONlTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 1ST
o 2ND
o 3RD
o 4TH
d belief that the information I provided is true a
o 0
o 0
o 0
o 0
diment exists
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, thal"toth
as to my right to enter into the marriage sta ,
21. SIGNATURE OF GROOM~'
23. SUBSCRIBED AND SWORN TO/AFItRMED BE ORE 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 Stale. 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
h
04/29/2009
ersFalls NY 12590
. STATE. ZIP
27. TYPE OF CEREMONY
o p;r RELIGIOUS
9 0 OTHER, SPECIFY
w
en
ffi ~
~ {SEAL}
'-v-I
NAME (PRINT)
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TITLE
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
AM
02:34PM
04
30
2009
06
28 2009
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNr-A'~a-.-IS!1fr
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
SPECIFY & /e'C /1,1 tJ/ ptA
/
SIGNATURE~