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COUNTY Dlltr.he~~
CITYfTOWN W::Irrinop.r
~~~:~c; 1 ~RR
~~~I:;~R R!=l
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Fr~~EPiill.lll:zzqMJrENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
TerubKf I ynn F~ENTSURNAME
~
1. . A FULL NAME
11. A. FUll NAME
FIRST
FIRST
B. BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 1 ? 1 - 7 4- ~R 1 ~
2 RESIDENCE A. NYsTATE) B. qcld~~e$$
C. CHECK ONE 0 CITY 2J TOWN 0 VILLAGE
AND n hk .
SPECIFY .0110 eer~IP
D. STREET ADDRESS ?406 Cherry Hill Drive ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A AGE 28 3B. DATE OF BIRTH MOQTt / ~~ / -l-iB-D-
4. EMPLOYMENT
A USUAL OCCUPATION Lawyer
8. TYPE OF INDUSTRY OR BUSINESS I p.g::l1
5. PLACE OF BIRTH Cormp.1 NY
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A NAME Frank Pallll:z::zo, Sr
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME r.hri~t::l n::lrlp.np. ~;:!inp.y
8. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. S~S~*~tA~~~~EA~~C~~S~o
D. SOCIAL SECURITY NUMBER 113-7/-6096
12. RESIDENCE A. NY B. [llltr.hp.~!:;
(STATE) (COUNTY)
C. CHECK ONE 0 CITY eJ TOWN 0 VILLAGE
AND P hk .
SPECIFY ntlg eepsle
D. STREET ADDREss2406 Cherry Hill Drive
13. A. AGE 26
3B. DATE OF BIRTH
11
MONTH
ZIP 12603
o YES~ NO
A!=lR1
YEAR
E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE?
AR
DAY
14. EMPLOYMENT
A. USUAL OCCUPATION I n;:!n Offir.p.r
B. TYPE OF INDUSTRY OR BUSINESS Banking
15. PLACE OF BIRTH Rhinebeck NY
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Rnhp.rt I Ip.wp.llyn Fngg. .Ir
. B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Margaret Sharon Oddo
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 -
o
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (,
MONTH OAY 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
o 0
o 0
o 0
o 0
that no legal impediment exists
C. DATE LAST MARRIAGE ENDED?
MONTH OA Y YEAR
D. ARE ANY FORMER SPOUSE(S) AUVE? 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
o
o
o
o
o
o
21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
w
en
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(,)
;:j
USE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New ork State of the bride and groom named above by any person authorized
Relations Law !l11 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
07/16/2008
by New York Domestic
~
{ SEAL }
'-v-I
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
DATE 07/16/2008
NY 12590
STATE ZIP
27. TYPE OF CEREMONY
o ,l)j(RELlGIOUS
9 0 OTHER, SPECIFY
AM
03:35PM
07
17
2008
09
14 2008
F
ITY WN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
AM
10 CIVIL
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY D \.( rc Hi' 55
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ISil"'TOWN OF 0 VILLAGE OF
SPECIFY r3"ttJ ( ~ tI t< ILl-
29. OFFICIANT e.el!
NAME (PRINT) .
'f!.~51
NAME (PRINT)
SIGNATURE~