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COUNIY Dutchess
CITYfTOWN Wappinger
~~~~~: 1368 .
~~~I:~~R 88
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MI~E!a n F u ItOtlURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
SarPa~~ L ordi FO~~H)r'~URNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~JNi~~~~t~~C~~stulton
D. SOCIAL SECURITY NUMBER 10'-68-6111
12. RESIDENCE A. NY B. Dlltr.hA~~
(STATE) (?jouNTY)
C. CHECK ONE 0 CITY III TOWN 0 VILLAGE
~~CIFY F~st Fishkill
D. STREET ADDRESS20 Valor Drive ZIP 12533
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES ~ NO
~~NTH ~1AY J(~~~
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) ,
D. SOCIAL SECURITY NUMBER nq7 -nn-n?n~
2. RESIDENCE A. NYSTATE) B. 9~ess
C. CHECK ONE 0 CITY oIlJ TOWN 0 VILLAGE
AND W .
SPECIFY ~rrmOAr
D. STREET ADDRESS 47 FdgAhill DrivA ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES ~ NO
3. A. AGE 27 3B. DATE OF BiRTH MoU / Q~ / ~79
4. EMPLOYMENT
A. USUAL OCCUPATION PhysiC'91 Th~rapist
B. TYPE OF INDUSTRY OR BUSINESS HA~lth r.~rA
5. PLACE OF BIRTH Pnt JnhkAAn~ip. NY
(CITY, $i'ATE I couIITRY IF NOT USA)
6. FATHER
A. NAME IO')Arh
B. COUNTRY OF BIRTH
13. A. AGE 23
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Phy~ir.::!1 ThAr~ri~t
B. TYPE OF INDUSTRY OR BUSINESS Health Care
15. PLACE OF BIRTH Bronx, NY
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME .ln~Aph AnnrAw Fngli~nn
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Diane Lynn Lordi'
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
l::!mA~ Fllltnn
IJRA
7. MOTHER
A. MAIDEN NAME ThArA~~ M~riA Pnnr~7::J
B. COUNTRY OF BIRTH I J R 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
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) (CITYICOUNTV. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. ".- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
YEAR
MONTH DAY
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) (CITYICOUNTV, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
hat no legal impediment exists
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swe!!r/affinn, aep'ose and say, th~t t e best of my knowledge and belief that the infonnation I provided is true and that I declar
as to my nght to enter Into the mapg~:/
21. SIGNATURE OF GROOM~ /.J ~ 22. SIGNATURE OF BRIDE~
, USE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK"
This license authorizes the marriage in New rk State of e bride and groom named above by any person authorized
W Relations Law ~11 to perfonn marriage ceremonies Within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
en 0 If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
Z ~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
W } NAME (PRINT) C. Mas rson
o { . TIME MONTH YEAR
:J SEAL SIGNATURE". DATE 08/08/2007
MAILING ADDRESS AM
'-v-' 20 Middl ush Rd. aooinaer Falls. NY 12590 06:22 PM 08 09 2007
STREET CITYii'15WN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME AY YEAR o~ RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
08/08/2007
DATE
by New York Domestic
MONTH
YEAR
10
07 2007
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNIY D u.tc.leJJ
29. OFFICIANT
NAME (PRI
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF}fA. TOWN OF 0 VltLA'}E ~F/ /
SPECIFY ~Q5' hrb I__
I
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