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CITY/TowMlHppingAr
~~~:~C~ ~nR .
~~~I:~~~ ~R
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFRDAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
J liioralD~miilnd B~&i~ SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
I Hllren PHtridH r.nrnHX
MIOorr CURRENT SURNAME
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
ll.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAG~~~~
(OPTIONAL - SEE REVER E
D. SOCIAL SECURITY NUMBER - 2-7725
12. RESIDENCE.N EW YORK {)11tr.hA~~
(STATE) (COUNTY)
C. CHECK ONE 0 CI1W"O TOWN 0 VILLAGE
~~~ClrFH~t Fi~hkill
D. STREET ADDREs43 Ninham Avenue
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSI;l
D. SOCIAL SECURITY NUMBER nn?-nR-?A.QA.
2. RESIDENCE ANeWT~9rk B. D~bbtmss
C. CHECK ONE 0 CITY 0 TOW~D VILLAGE
~~~CIFYW(;lppinOAr~ FHII~
D. STREET ADDRES01 RhlHrt AVAnLJA ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? Y!J YES 0 NO
3. A. AGQ8 3B. DATE OF BIRTH ~~H /O~Y ,/-j~9
4. EMPLOYMENT
A. USUAL OCCUPATIONEinancial SpE'Ci(;lli~t
B. TYPE OF INDUSTRY OR BUSINEssWHr.hnviH
5. PLACE OF BIRTtRhinAhAr.k !\lAW Ynrk
(CITY, STATE I cot.lNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATlorf)AntHI A~~i~tHnt
B. TYPE OF INDUSTRYOR BUSINESCiovaccio & Valente
15. PLACE OF BIRT~1ount Vernon, New York
(CITY. STATE I COUNTRY IF NOT USA)
ZI~ 2590
o YE!J"'D NO
14R1
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGt26 3B. DATE OF BIRTH OR ?4
MONTH DAY
6. FATHER
16. FATHER
A. NAM{)Ani~ r.nrnHX
'B. COUNTRY OF BIR-rW S A
17. MOTHER
A. MAIDEN NAMeMHry Curran
B. COUNTRY OF BIR-rW S A
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
A. NAMEDennis Benedict BiilrrE'si
B. COUNTRY OF BIRTHI J S A
7. MOTHER
A. MAIDEN NAME RhnnrlH SIIA Prir.A
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. - YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
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) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.ose and s I to the best
as to my right to enter into the./" ~~~~
21. SIGNATURE OF GROOM ~~ ·
USE CURR NT
23. SUBSCRIBED AND S N TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York St. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used on y for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
o
o
o
1ST
2ND
3RD
o 0
o 0
o 0
o 0
at no legal impediment exisls
by New York Domestic
~
{ } NAME (PRINT)
SEAL SIGNATURE ~ DATE 10/23/2007
MAILING ADDRESS
'-v-' 20 Middleb ers Falls NY 12590
STREET ClOWN STATE ZIP
~~~R~~RT~~~ 'o~O~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27 "-,PE OF CEREMONY
SONS NAMED ABOVE ON THE TIM M. DAY YEAR 0 ~ RELIGIOUS 1 0 CIVIL
~~~E ~~glt.-;':~E TIME AND .2. : 30 AM I f I 0 /) +- 9 0 OTHER, SPECIFY
29. OFFICIANT F(. G..v.,.; ( (w mtJ /' j-A fA ...., .,... tf..
NAME (PRINT) '4Jltor oK TITLE ra (,f
IJ M.JI.4~, ~ DATE II / / pi () '"?
\J a ((.w eJ fa ~u~, ; e-. flY (J,(p 03
---TCITY/TOWN STATE ZIP
31. WITNESS TO CEREMONY
5t I,flPi
TIME
MONTH
YEAR
9:46 AM
PM
o
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY
1);\ +- ~;;.s
SIGNATURE ~ g It ,
MAILING ADDRESS
{IK U&.Ctt"
STREET
30. WITNESS TO CEREMONY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF [!(TOWN OF 0 VILLAGE OF
SPECIFY 1'00. ~ lr\ \:: ~ Jt ~ ~; e,
NAME (PRINT)
SIGNATURE~
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)