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DISTRI4P.68
NUMB~
REGISTRQ
NUMBE"'~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Barne~DMichael Hac~l~NT SURNAME
I"
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Josine C Flaaello
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
0..
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERllS-1 56 9829
D. SOCIAL SECURIiY NUMBER UO - -
2. RESIDENCEfijEW YORK Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CI~ 0 TOWN 0 VILLAGE
~~cIFWappinQer
D. STREET ADDRElsO pye Lane
Zl~ 2590
o ~D NO
A967
YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIActEI a b I e
(OPTIONAL. SEE REVERs&'3 50 7834
D. SOCIAL SECURIiY NUMBER I,) - -
12. RESIDENCNEW YORK Qutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CI-M 0 TOWN 0 VILLAGE
AND 'M .
SPECI"",.appmQer
D. STREET ADDR~ Pye Lane ~~590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 y(s 0 NO
13. A. A&Q 3B. DATE OF BIRTH 07 3Y 1900
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. Aaa 3B. DATE OF BiRTH 07 )1"2
MONTH DAY
W
S
en
4. EMPLOYMENT
A. USUAL occuPATlolrack Worker
B. TYPE OF INDUSTRY OR BUSINE&Metro-North
5. PLACE OF BIJ'~ew York, New York
(CITY, STATE I COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCcuPATIQffice Manager
B. TYPE OF INDUSTRY OR BUSINE!~surance
15, PLACEOFBIR~onx, New York
(CITY, STATE I COUNTRY IF NOT USA)
~
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6. FATHER
A. NA~ames F. Hable
B. COUNTRY OF BI~ S A
7. MOTHER
A. MAIDEN NAM~argaret O'Brien
B. COUNTRY OF BIRJ.J S A
8. NUMBER OF THIS MARRIAG~
16. FATHER
A. N~io D. Flagello
'B. COUNTRY OF BI~ S A
17. MOTHER
A. MAIDEN NA~nna Josephine Mione
B. COUNTRY OF BI~ S A
18. NUMBER OF THIS MARRIAG~
9 PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
. A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT DEATH
2 0 0 2 0 0
B. HOW DID LAST MARRIAGE END? ~ 0 DIVORCE (3) 0 ANNULMENT (g),D DEATH B. HOW DID LAST MARRIAGE END? ~ 0 DIVORCE (~ 0 ANNULMENT J2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 1 0 /24 /1997 ' C. DATE LAST MARRIAGE ENDED? 12 L! 9 )t98b
M~ DAY YEAR M~ DAY" / YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
JMONTH. DA~YEAR) (CITY/COUNTY. STATEICOUNTRY, IF NOT USA) SELF SPOUSE ...lMONTHr,DA}<. YEAR) (CITYICOUNTY. STATElCOUNTR\If NOT USA) SELF SPOUSE
1s9;:s/19/20u2 Bridgeport, Connecticut 0 toI 0 1s1L/16/~Ou5 Poughkeepsie, New T ork toI 0
2NaO/24/1997 Carmel, New YorK . 0 toI 0 2N~2/19/19l:Sb JaCKSOnville, t-Ionaa toI~ 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I du swear/affirm, dep.ose and nowledge and belief that the information I provided is no Ie al impediment exists
as to my right to enter into
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21. SIGNATURE OF GR
22. SIGNATURE OF BRIDE"
23. SUBSCRIBED AND SWO FlRMED
SIGNATURE OF TOWN OR CITY CLERK
This liCense authorizes the marriage in New Yo tate of e bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within 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.
~ 24. TOWN OR r.1T)' C~K M t 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINTt'_on ~Li. as erson
{SEAL SIGNATURE~ / DA,.Q7/11/2007 TIME
"-v-I ~'Mi~ Rd, W ppinger Falls, NY 12590
STREET CITYITOWN ZIP
~~~R~~RT~~~ IO~O~N~~E~ 26. SOLEMNIZATION OCCURRED
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR
~t.r6E ~gIC'}.\~E TIME AND '0 7/ ~ I 10"
............ ---"
~,;",{.(y C "';'J'"
_2~ -c ~
,
]~OCA. .,J'
CITYfTOWN
by New York Domestic
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
YEAR
1 !3'"t:IVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~'(dUJ
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
29. OFFICIANT
NAME (PRINT)
TITLE c.~ G..,l
,
DATE ',4~~ 7
AJ.Y.
STATE
J...~,,-
...
o CITY OF ~OWN OF 0 VILLAGE OF
~~~ll/
SIGNATURE ~
"ILING ADDRESS
,-.U. ~O)C PrY
STREET
3D. WITNESS TO CEREM
SPECIFY
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
NAME (PRINT)
SIGNATURE~
