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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
\f' t 1 .
. Ira~f1 ~gCCIS~9lil\NT SURNAME
o 0 1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTH 12 / D1vS / ~7 C. DATE LAST MARRIAGE ENDED? MONT!?6 / ~A~ .f. 12..~Fi
D. ARE ANY FORMER SPOUSE(S) AliVE? Iiil'YES 0 NO D. ARE ANY FORMER SPOUSE(S)ALlVE? ~ YES 0 NO
..
1D. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, D~, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (ClTYtCOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 12/18/2007 White Plains, New Yorl< ~ 0 1ST 06/1Q/1996 PnllohkF!F!p~iF!. NF!W Ynrk 0 ~
2ND 0 0 2ND 0 0
3RD 0 D 3RD 0 .0
4TH l._' D 4TH 0 0
I duly swear/affirm, depose and say, th ge and belief that the information I provided is true and that I declare that no legal impediment exists
::. :G:~i~:: t:Fe::::~o~he marn 22. SIGNATURE OF BRIDE. .. ''7frJ.' ..' . (j. /!~~
..' CURRENT NAJrt'
23. ~::'~~~~Do~N.fo~~Oo~ d~Abr~~:~ B DATE 01 In?/?OOR
This license authorizes the marriage in New Y State 0 the bride and groom named above by any person authorized by New York Domestic
Relations LaWi~1MHP~rf()rm marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK ST~TE 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
COUNTYDlltd"lF!SS
CITY/TOWN W;:!ppinOF!r
~~J:~:136R .
~5~~J~R 1
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 062-36-1297
2. RESIDENCE A. N'(STATE) B. ~~ess
C. CHECK ONE 0 CITY,jJ TOWN 0 VILLAGE
~~~CIFY Fiihkill
D. STREET ADDRESS 1511 M9X W~y ZIP 1 ?5?A.
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES~ NO
3. A. AGE60 3B. DATE OF BiRTH M~ / 6\0 / ~4 7
4. EMPLOYMENT
A. USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS Food Indllstry
5. PLACE OF BIRTH~mXR}~~
6. FATHER
:~. ,~AMf._Fr3nk Loccis3no
~.COU~Y OF BIRTH U S 11
7. MOTHER
~. MAIDEN NAME Rose Caputo
B. COUNTRY OF BIRTH U S ~
8. NUMBER OF THIS MARRIAGE ?
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
l)IVORCE'--'--~'-' w" ._, 'CIVIL ANNULMENT'
DEATH ,-
1
W
en
z
W
o
::l
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
MAILING ADORES
~ .
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
OATE AND AT THE TIME AND
PLACE INDICATI'D.
29. OFFICIANT .
NAME (PRINT)
TITLE
DATE
/::..,
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11.1 11 Ct' .
l'lao,bJtE an ar!QlRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. S~S~~JN~rr~~~t~~C~~sQantarini locci5lilnO
D. SOCIAL SECURITY NUMBER 0f\R..A.R-1 QA.~
12. RESIDENCE A NY(STATE) B.~SS
C. CHECK ONE 0 CITY,jlJ TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDREss1 fi 11 M::!)( W::!y ZIP 1 ?fi24
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES otJ NO
13. A. AGE51 3B. DATE OF BIRTH Q.~NTH ~QAY -1~a&
14. EMPLOYMENT
A. USUAL OCCUPATIONAdministrati\le I1ssistant
B. TYPE OF INDUSTRY OR BUSINESS Erh Ic;:!tinn
15. PLACE OF BIRTH Manhattan N€'w vnrk
(CITY, STATE I COUrlrrRY IF NOT USA)
16. FATHER
A. NAMEAdolfo Vincent Cantarini
'B. COUNTRY OF BIRTf4taly
17. MOTHER
A. MAIDEN NAME Clementina [1'Onofrio
B. COUNTRY OF BIRTH I S 11
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
TIME
MONTH
YEAR
MONTH
YEAR
AM
06:31 PM 01
03
2008
03
02 2008
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
Du ~.\f
A. STATE NEW YORK B. COUNTY
f{ ~ve~
~/~/clK-
/~r.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF jl!l TOWN OF 0 VILLAGE OF
SPECIFY F,") h k-, J I
STATE
NAME (PRINT)
SIGNATURE~