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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thomas Paul MaQliochetti
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfroWN Wappinger
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1. A FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)073_46_4568
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C CHECK ONE D CITY '6 TOWN D VILLAGE
~~~CIFY WappinQer
D STREET ADDRESS 1 Truffle Ridge Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES '6 NO
04 / 25 / 1953
MONTH DAY YEAR
3. A. AGE 55
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION DEP
B. TYPE OF INDUSTRY OR BUSINESS DEP
5. PLACE OF BIRTH Queens, Ny
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Anaelo P. Maaliochetti
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Patricia Testagrossa
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 3
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Barbara Elaine Merker.
~
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE MaQliochetti
(OPTIONAL. SEE REVERSE) 107 -46-4850
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 1 Truffle Ridge Road
MONTH
ZIP 12580
DYES '6 NO
)1'953
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 55 3B. DATE OF BIRTH 11 /1 0
DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Medical Transcription
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH Tarrytown, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Alfred Dewitt Merker
'B. COUNTRY OF BIRTHU SA
17. MOTHER
A. MAIDEN NAME Patricia Van Wass
B. COUNTRY OF BIRTH Canada
18. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT
2 0 0 1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) D ANNULMENT (2) D DEATH B. HOW DID LAST MARRIAGE END? (3) 6 DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 07 / 06 / 1992 c. DATE LAST MARRIAGE ENDED? 11 / 23 / 1983
MONT'too DAY YEAR MONTr[,;o 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, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
07/06/1992 Carmel, Nv ~ D 1ST 11/23/1983 White Plains, Ny 0 6
04/27/1983 Carmel, Ny d D 2ND 0 D
D 0 3RD 0 D
D 4TH 0 D
and belief that the information I provided is true an~ that no legal impediment exists
~~~~
22. SIGNATURE OF BRIDE~ .'
USE CURRENT NAME
21. SIGNATURE OF GROOM~
US
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in Ne ork 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) John C. Masterson
TIME MONTH YEAR
SEAL SIGNATURE ~. DATE 12/04/2008
MAILlIiG f.QPREI?S AM 2
'-v-I 2u Mlddl ush Rd, WappinQers Falls, NY 12590 4PM 1
STREET CITY/TOWN STATE ZIP
~~~R~~RT~~~ lo~O~~~N~zi~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 D RELIGIOUS
DATE AND AT THE TIME AN
PLACE INDICATED. 0 OTHER, SPECIFY
DEATH
o
DATE
12/04/2008
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
05
2008
02
02 2009
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEWYORK B.COU~~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
D CITY OF 0 TOWN OF ~LLAGE:'- j j ~
SPECIFY ~~P,itA>ll~ ~
o
SIGNATURE~