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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 MichMlESt~ph~n ~L~~~ SURNAME
FIRST
I
STATE FilE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
couNTYDlJtchp.~~
CITYrrOWNWFlrringp.r
~~J:~~T.t 30R .
REGISTE~O
NUMBER
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
AI~~~ ninan7i~URRENT SURNAME
~
11. A. FULL NAME
n.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1?!=i-7A.-O?A.R
2. RESIDENCEA.N~STATE) B. D~ss
C. CHECK ONE 0 CIT'II,I(] TOWN 0 VilLAGE
~~~CIFY F=i~hkill
D. STREET ADDRESS 1 ?OR Pondvip.w loop ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIllAGE? 0 YESo"tJ NO
3. A. AGr:24 3B. DATE OF BIRTH M~ / Q~ /"v~~2
4. EMPLOYMENT
A. USUAL OCCUPATION Police Officer
B. TYPE OF INDUSTRY OR BUSINESS Town Of Np.whllrgh
5. PLACE OF BIRTt-Rrnm( Np.w Ynrk
(CITY, ST,(TE I COUNTRY IF NOT USA)
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. sVS~~~~~~~t~~~~~~isia
D. SOCIAL SECURITY NUMBER 1 ?3-00-1 ROO
12. RESIDENCE 1NY Ilnlltr.hp.~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY..tJ TOWN 0 VILLAGE
~~~CIr=EFl~t Fi~hkill
D. STREET ADDREs9. Barnes Drive
z,P12590
o YE~ NO
j.oQ7Q
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIllAGE?
13. A. AGF!2.7 3B. DATE OF BIRTH OQ ?'1
MoNTH DAY
14. EMPLOYMENT
A.' USUAL OCCUPATlotl)Flyr.::lrp. nirp.r.tor
B. TYPE OF INDUSTRY OR BUSINEssTots N Us
15. PLACE OF BIRTHYonkers, New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMB-Ip.nry Frlw::lrrl nin::ln7io
'B. COUNTRY OF BIRTU S A
17. MOTHER
A. MAIDEN NAMELorrFline Mary DeSantis
B. COUNTRY OF BIRTU 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
6. FATHER
A. NAME Michael Ralph Sisia
B. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A. MAIDEN NAME M::lry Ff/p.n ~h Irnp.r
B. COUNTRY OF BIRTH I J ~ A
8. NUMBER OF THIS MARF,UAGE 1
9. 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 (3) 0 ANNULMENT (2) 0 DEAJH
C. DATE LAST MARRIAGE ENDED? / /
, MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
-10.IF-PREVI0USLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, 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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
'-.- YEAR
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 swear/affirm, deP.OSe 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 right to enter into the mamage s . .
21.SIGNATUREOFGROOM~ USEC RRE "NA" 2 SIGNATUREOFBRIDE~~ I ~~~~t'\ ~
23. ~~J~=~DO~~O~~OO~ ci~Abr:rR~E~ BEFORE ME DATE 08/09/2e07
This licanse authorizes the marriage in New York State by New York Domestic
Relations Law ~11to perform marriage caremonies within New Y . State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used 'only for the urpose Dla second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) J~MaS~r on
{SEAL SIGNATURE ~ . c. ~..~ DATE 08/09/2007 TIME YEAR MONTH
MAILING ADDRESS 1 0 08 2007
'-v-I ST~~ Middlebu Rd. WaDDJ~~~ Falls. N~TE 12590 ZIP
~:RJ:RT~J ~~O~~N~~E~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. Y YEAR 0 ~ELIGIOUS
DATE AND AT THE TIME AND .AM- 0- "
PLACE INDICATED. ~CO PM 0 &.7 O,! 90 OTHER, SPECIFY
29'OFFICIANT~:;#: ~)2~" .cJ r-~.t r.'-R'"
NAME(PRINT). =tlL-"'~IC:C-O TITLEI~~ ~UAL Y"\e&
SIGNATURE~___= =~____~TE )'\-u.5U~T 01. ~I ~OO '7
MAILING ADDR S
s,e~~ L ~r)( <f il CI~~ '- \ C. j-. I I S,)JE L i \ d-.S-.3 :~ ZIP
30. WITNESS TO CERE'tONY 31. WITNESS TO CER MONY
NAME (PRINT) IA ~ i\- \.........., O. c;;:- \ '" \ Q NAME (PRINT)
..A ./ ..$ c-' \
SIGNATURE~ ''-''7 ~-. I . ~A~ SIGNATURE~
bOH-98 (03/2006)
YEAR
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
STATE NEW YORK B. COUNTY \)~
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF !UA'OWN OF 0 VILLAGE OF
SPECIFY e.'A.rl -:::g... ,'5 k..\u II