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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Christ~Po~~r Lee BI~~~E~}IS~RNAME
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swellr/affirm. depose and say, that to the best of my knowledge and belief that the information I provided is ~r and that I declare that no legal impediment exists
as to my nght to enter Into the ama state. ~ I f1 A__
21. SIGNATURE OF GROOM k... 22.SIGNATUREOFBRIDE~ 'AuP~' ~
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE r:i C E~AME E CURRENT NAME 10/06/2008
SIGNATURE OF TOWN OR CITY CLERK ~ l.~. DATE
This license authorizes the marriage in New ork State of the bride and groom named above by 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.
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
n C. M
COUNTY Dutchess
CITYfTOWN Wappinqer
~~~~~~ 1368
~~~I~~~R 1 57
1 . A. FULL NAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 8 0075
D. SOCIAL SECURITY NUMBER 110-5-
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITYoCI TOWN 0 VILLAGE
AND W .
SPECIFY apPlnger
D STREET ADDRESS 163 Cider Mill Loop ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES~ NO
04 /28 /1975
MONTH DAY YEAR
3. A AGE33
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION T elecom Tech
B. TYPE OF INDUSTRY OR BUSINESS Telecom
5. PLACE OF BIRTH New York. Nv
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Larry Bloncourt
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mvrna Velez
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
w
en
z
w
(,)
::::i
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
'-y-I MA~~G~i~a
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE 10/06/2008
in ers Falls, NY 12590
CITYrrOWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 ~GIOUS
f ( 9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
TITLE
...,...~
--.J;
(THIS SPACE FOR 5T A TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Antonella Joanne Mistretta
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Bloncourt
(OPTIONAL. SEE REVERSE)114_ 7 2 - 7568
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(STATE) (COUNTY)
c. CHECK ONE 0 CITY '6 TOWN 0 VILLAGE
~~~CIFyEast Fishkill
D. STREET ADDRESs18 Buroak Drive
ZIP 12533
o YES '6 NO
,%976
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE32 38 DATE OF BIRTH 07 ~3
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Account Manager
B. TYPE OF INDUSTRY OR BUSINESS Health Care
15. PLACE OF BIRTH Yonkers, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Baldo Mistretta
'B. COUNTRY OF BIRT~taly
17. MOTHER
A. MAIDEN NAME Agnese Elvira Poggiogalle
B. COUNTRY OF BIRTH1ta1y
1 B. 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) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (,
MONTH DAY YEAR
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
TIME
MONTH
YEAR
MONTH
YEAR
10:47AM
PM
10
07
2008
12
05 2008
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 7:;;rtrifFSS
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY 'JI{;/TfJf!/~ b-G'RJ.' f;:;..u..s
R. C, PP-li?i:r
II /'ir ~8'
. 2~'lC
ZIP
31. WITNESS ~EREMONY
NAME (PRINT)
SIGNATURE~
./v-