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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mi~~1 Bagarq,~NT SURNAME
COUNTY Dutchess
CITYfTOWN \l\Iappinger
DISTRICT .
~~~~~~R1368
NUMBER 1 38
1 . A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 116 72-5325
2. RESIDENCE A. NV B. no .t,..hess
'STATE) '"'(co'OO'l)
C. X~5CK ONE 0 CITY JJ TOWN 0 VILLAGE
SPECIFY Beekman
D STREET ADDRESS 139 Benton ~"oore Rn(;lrl ZIP 1 ?fi~~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YESolJ NO
MOt~ / ~1 / ~4
3. A. AGE 23
4. EMPLOYMENT
3B. DATE OF BIRTH
~
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<I:
A. USUAL OCCUPATION Mason Foreman
B. TYPE OF INDUSTRY OR BUSINESS Constp Iction
5. PLACE OF BIRTH ~1~'~.m\E~~U~&Y 1t'l~T USA)
6. FATHER
A. NAME Baldassare M. Bagaro~i
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A MAIDEN NAME Marietta \/alentina Mascia
B. COUNTRY OF BIRTH I I S A
B. NUMBER OF THIS MARRIAGE. 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) 0 DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
(TH/S SPACE FOR 5T A TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Brittan~IDb?forgianl"1 @mi#1uRNAME
~
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. sVS~~~M~~~rt~~b~~~agarozzi
D. SOCIAL SECURITY NUMBER ?44-R~-fin? 1
12 RESIDENCE A NY(STATE) B.DI(b~<6~SS
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Rp.p.km~n
D. STREET ADDREss139 Benton Moore Road
ZIP 12533
DYES -tJ NO
",1987
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE?
13. A. AGE20 3B. DATE OF BIRTH 11 ~7
-----"MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Cosmntnlno i!=:t
B. TYPE OF INDUSTRY OR BUSINESS Cosmotology
15. PLACE OF BIRTH North C::lrolina
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Palll St::ln1ey Smith
'B. COUNTRY OF BIRTJJ S A
17. MOTHER
A. MAIDEN NAME Avis Dianne Vick
B. COUNTRY OF BIRTHl J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
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
cr:'
W
III
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1 ST 0 0 1 ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, Depose and say, that to the best of my knowledge and belief that the information I provided is tru
as to my right to enter into the mamage state.
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF BRIDE~
o 0
o 0
o 0
o 0
and that I declare that rJo Ie al impediment exists
23. SUBSCRIBED AND SWORN TO/AFFIRMED B
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New rk 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.
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
~
{ SEAL }
'-...-'
NAME (PRINT)
DATE
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
AM
03:24PM
09
13
2008
11
11 2008
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME ANO
PLACE INDICATED.
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
1,_ CIVIL
/
.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY D;J~H-e.ss
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY~1' iN 6/f R..
TITLE B(;EI(M~ 'TWJJIi J"~h~'
DATE 09 -.~7 - 08
N,' r'Z
STAT
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-9B (03/2006)
--
NAME (PRINT)
SIGNATURE~