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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Mi~~JEAntonio ~-?SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COUNTY nllkhp.!,:!,:
CITYfTOWN W~ppinop.r
~~~~~c~ 13RR '
~~~I:~~R 1 ?7
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
'nseplJil!~ M~ry r.~[~~fN.P~RNAME
-.J
11. A. FULL NAME
FIRST
11.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. s~~~~~,,~~~~t~~C~~sRiego
D. SOCIAL SECURITY NUMBER 069-66-9046
12. RESIDENCE A. NY B. n..tr.hp.!,:!,:
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN iiiiI' VilLAGE
~~~CIFY W::lrpingp.rs F::llIs
D. STREET ADDRESS 81 South Mesier Ave. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? !'l YES 0 NO
13. A. AGE 26 3B. DATE OF BIRTH 01 /?? AQR1
MONTH DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) ,
D. SOCIALSECURITYNUMBER n7n-RR-Q~?R
2. RESIDENCE A. N';(TATE) B. Qmess
c. CHECK ONE 0 CITY 0 TOWN ~ VilLAGE
~~~CIFY \N~ppinop.r!': F~II!':
D. STREET ADDRESS R1 SnlJth Mp.sip.r Avp. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? M' YES 0 NO
3. A. AGE 25 3B. DATE OF BIRTH MO~.g / ~ / Y~
4. EMPLOYMENT
A. USUAL OCCUPATION H\I AC
B. TYPE OF INDUSTRY OR BUSINESS HV Ar.
5. PLACE OF BIRTH Pm Jllhkp.p.n!':ip. NY
(CITY, STlITE I COutlTRY IF NOT USA)
6. FATHER
A. NAME Alberto r"liego
B. COUNTRY OF BIRTH Mp.xir.n
7. MOTHER
A. MAIDEN NAME r.hri!':tin~ Ann Pnlir.h::lk
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 ...."~'CIVll 'ANNl:JtMENT
o 0
DEATH
o
l-
S;
cc
c
wLL
u..
-cc
14. EMPLOYMENT
A. USUAL OCCUPATION M~rkp.ting
B. TYPE OF INDUSTRY OR BUSINESS Marketing
15. PLACE OF BIRTH Brooklvn, NY
(CITY. STAT~ I COUNTRY IF NOT USA)
16. FATHER
A. NAME .In!':Aph ~inrrl~nn
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Vincp.nta Marianne Vaccaro
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
".- YEAR
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
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is true
as to my right to enter into the ma~l'Iage te. .
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF BRIDE~
o 0
o 0
o 0
o 0
d that I declare that no legal impediment exists
~~
USE CURRENT NAME
W
UJ
Z
W
(,)
::J
US
23. ~::Jl~=~Do~N.fo~~Ot~ ci~A CL~~E~ BEFORE ME DATE 09/26/2007
This license authorizes the marriage in New Y. ride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies hin 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,
r-I'-.. 24. TOWN OR CITY CLERK 25, A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) J
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ DATE 09/26/200
'- .-J MAII.l"LG e.QPIIFjE~S AM
-v- LV M 001 appinQers Falls, NY 12590 04:52PM 09 27 2007 11 25 2007
STREET CITYITOWN STATE ZIP
~~~R~~RTr~~ 10~O~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ELlGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 10 /;1 c1 DO 1 9 0 OTHER, SPECIFY
29. OFFICIANT Cf4.cc H-iOt4.TIT-lE '-DL::- Jttc. Ot'1
NAME (PRINT)
SIGNATURE ~ DATE I (J' II;L / (j 7
MAILING ADDRES . .-. ,AL' - --p, I) I
(I i.-/-r, QffteJ.1 C'L~ 4-c l: ,auGft ~~.m= ,,7"~ /2- 0b i
STREET / CITYfTOWN STATE ZIP
30. WITNESS TO 31. WITNESS TO CE EMOl'lY;
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVil
A. STATE NEW YORK B. COUNTY
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ OF 0 TOWN OF 0 VilLAGE OF
SPECIFY fb13 ~ k P'f>pS it-
NAME (PRIND
SIGNATURE ~
DOH-9B (D3I2006)
SIGN