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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
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.InC~lDll\.l?"osepll uCUJ~AURNAME
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 swear/affirm. depose and a I that to t e b nowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the r1qge sta . ~
21. SIGNATURE OF GROOM ~ ' " 22. SIGNATURE OF BRIDE ~ 1d.. ~ k . (:), d. ~~~
USE CURRENT NA~ USE CUR~NAME ~
23. SUBSCRIBED AND SWORN TO/AFFIRMED EFOR~I1...... . ~/ /l< A ,.4"'0
SIGNATURE OF TOWN OR CITY CLERK,- L ~A' V I _~~&-C -1. _ DATE _ ___
This license authorizes the marriage in New York 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
COUNTY Dutchess
CITYITOWN Wappinger
~~J:~c; 1 368 .
~5~~~~R 1 06
1. A. FULL NAME
FIRST
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B. BIRTH NAME. IF DIFFERENT
+
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 064-78-1549
2. RESIDENCE A. CT B. H-::ar-+fnrd
. !$TATE) (CO!mff!
C. CHECK ONE 0 CITY.,Ill TOWN 0 VILLAGE
AND 0 I'
SPECIFY E.1Ur Ington
D. STREET ADDRESS 14 Orchard Road ZIP 060 1 ~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES~ NO
MJJ~ / Q.~ / W5
3. A. AGE 33
4. EMPLOYMENT
3B. DATE OF BIRTH
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A. USUAL OCCUPATION IT
B. TYPE OF INDUSTRY OR BUSINESS Sen/ice
5. PLACE OF BIRTH PN~~ilj} ~~
(c. I Y 'N SA)
6. FATHER
A. NAME Joseph Anthony D'iorio
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Glori; Bernadette Molle
B. COUNTRY OF BIRTH U S 4,
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH 01'. Y 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
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SIGNATURE'-
DOH-98 (0312006)
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Debra ~~!en StaLlff~~~~URNAME
.-J
11. A. FULL NAME
FIRST
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. sYS~~~;,.~~~rEA~WC~~J?'lorio
o SOCIAL SECURITY NUMBER '73-80-3174
12. RESIDENCEA.CT(STATE) B,Hw~d
C. CHECK ONE 0 CITY,j2I TOWN 0 VILLAGE
AND B j'
SPECIFY Ilr Ington
D. STREET ADDREss14 Orr.h;:trn Ro;:tn ZIP06013
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES olJ NO
13, A. AGE30 3B. DATE OF BIRTH ~TH /()~AY ,{~Zt
14. EMPLOYMENT
A. USUAL OCCUPATION Physical Therapist
B. TYPE OF INDUSTRY OR BUSINESS Ml'!rlir.;:t1
15. PLACE OF BIRTHZanes\lille Ol1in
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
,A. NAME Rich;rd Ray StaLlffacher
B. COUNTRY OF BIRTHlI ~ A
17. MOTHER
A. MAIDEN NAME Helen Mcrth61 R;:!thm;:!nn
B. COUNTRY OF BIRTHII S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'~ YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH OA Y
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
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
YEAR
MONTH
DAY
YEAR
MONTH
09:12~~ 08
10
13 2008
15
2008
28, PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN-:;JJIJ.rt.Hdi
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ OF TOWN OF 0 VILLAGE OF
uk tf-fC:aCL ff ~t.
SPECIFY