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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 Da~ Francis ~JM2SrSURNAME
I
STATE FILE NUMBER
(rHIS SPACE FOR STATE USE ONLY)
I
COUNTY nlltchAl';l';
CITYITOWN WBppingAr
~~~:~crJ 1 ~nR .
~5~I:J~R 100
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
n::lni~IL~LJ IIr.iIIA r.i~Gkg!~ SURNAME
~
11. A. FULL NAME
FIRST
n.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Flliot
D. =~~~~~:~u~~~~Rsm-062_70_0317
12. RESIDENCE A. Fl B. PinAII::I~
(STATE) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~CIFY Clearwater
D. STREET ADDRESS3386 Thalia Court
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) ,
D. SOCIALSECURITYNUMBER 107-7?-n107
2. RESIDENCE A. F~STATE) B. ~~~)as
C. CHECK ONE oiJ CITY 0 TOWN 0 VILLAGE
~~~CIFY r.IABrw::ltAr
D. STREET ADDRESS 3386 Thalia Court ZIP 33761
E. IS RESIDENCE WIlllIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
3. A. AGE 28 3B. DATE OF BiRTH OQ / 07 /1 Q78
MONTH DAY YEAR
E. IS RESIDENCE WIlllIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE ?A 3B. DATE OF BIRTH O~ Ao
MONTH DAY
ZIP 33761
o YES~ NO
;(qR~
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION r.Br RAntBIl';
B. TYPE OF INDUSTRY OR BUSINESS Enterprise Rent A Car
5. PLACE OF BIRTH Rhinebeck, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME WBltAr HArmBn Fllint
B. COUNTRY OF BIRTH Netherlands
7. MOTHER
A. MAIDEN NAME Donna Anne Patricola
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Cashier
B. TYPE OF INDUSTRY OR BUSINESS Wal Mart
15. PLACE OF BIRTH Mount Kisco. New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Joseph Frank Ciraolo
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Elizabeth Dawn Valleio
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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(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) (CITYICOUNTY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES D 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
a:
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1ST
2ND
3RD
4TH
I duly swear/affirm, aep'ose and s
as to my right to enter into the mf
21. SIGNATURE OF GROOM~ l
o
o
o
1ST
2ND
3RD
USE CURR
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the ~rriage in New York State of the ride and groom named above by any person authorized
Relations Law ~11 to perform mJrliage ceremonies within New York Sta . THIS LICENSE VALID IN NEW YORK STATE ONLY.
!!'l" If checked, this license is to be used only for the purpose of a second or subsequeni ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) J n C. Mast rs n
{ ~ ~ ~
SEAL SIGNATURE~ .
'-v-I MA~~lW'crm~b sh Rd, 11 :36 AM 08 27 2007
STREET PM
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
MONTH
YEAR
10
25 2007
28. PLACE WHERE MARRIAGE OCC~
A. STATE NEW YORK B. COU \4. ~\&
C. LOCATION OF CEREMONY
(CH?, ONE AND SPECIFY)
IJtCITY OF 0 TOWN OF 0 VILLAGE OF
SPEC,:+:6 ~ *tC~(.1S J ~
NAME (PRINT)
SIGNATURE~
OOH-9B (0312006)
NAME (PRINT)
SIGNATURE~