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COUNTY Dutchess
CITYrrowN Wappinger
~~~:kc: 1368
~~~I~~~R 52
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thnm::J~ .ln~Arh I ACnlmt
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ann Marie Bellantoni
MIDDLE CURRENT SURNAME
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0.
N
B. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE I ACount
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 065-62 -5266
12. RESIDENCE A.NY BDutchess
(STATE) (COUNTY)
C CHECK ONE otJ CITY 0 TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eeosle
D. STREET ADDREss3605 Deer Path ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
~6 )(978
DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 450-77 -9710
2 RESIDENCE A. NY B. nlltr.hA~~
(STATE) (COUNTY)
C. CHECK ONE \lJ CITY 0 TOWN 0 VILLAGE
AND P hk .
SPECIFY nug eepsle
D STREET ADDRESS 3605 Deer Path ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
n? /?R /1Q71
MONTH DAY YEAR
3B. DATE OF BIRTH
03
MONTH
13. A. AGE ~n
3. A. AGE 37
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION r.nn~tn Idinn
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH Yonkers NY
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Thom::J~ H I Ar.nl Int
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Cheryl Ann Lennox
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Westchester ECS
15. PLACE OF BIRTH Middletown. NY
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Rocco Bellantoni Sr
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A MAIDEN NAME Ann Patricia Petitto
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
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(2) 0 DEATH
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
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
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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 sweilr/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my nght to enter Into th~ m~rr tate. ~ / rI ~..,
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF BRIDE~ \-. ~- ~ L
""-- ENT NAME
23 ~~~fT~~~DO~N,.oo~~OtRN ci;~A6~:f:E~ B DATE 05/16/2008
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relatipns 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 pf a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL }
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NAME (PRINn
YEAR
MONTH
YEAR
TIME
MONTH
AM
12:35PM 05
17
2008
07
15 2008
WN
STATE
27. TYPE OF CEREMONY
o ~ELlGIOUS
9 0 OTHER, SPECIFY
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 1::\ l A::c""'5'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~N OF 0 VILLAGE OF
Qe..;'
TITLE .
SPECIFY u... n r?: i'\ ':j s) II
S E
30. WITNESS TO CEREMONY
NAME (PRINn LAvJ Q..E N CE:
SIGNATURE~ ~
DOH-98 (0312006)
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uJ
SIGNATURE~