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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
William Edward Mancusi. III
FIRST MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITYiTOWN Wappinger
~~~~~c~ 1368 .
~5~:;~R 55
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jennifer Lynn Rosi
MIDDLE CURRENT SURNAME
11. A. FUU NAME
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N
B. BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE Mancusi
(OPTIONAL - SEE REVERSE) 131 74 2164 (OPTIONAL - SEE REVERSE) 061-74-4640
D. SOCIAL SECURITY NUMBER - - D. SOCIAL SECURITY NUMBER
2 RESIDENCEA. New York B. Dutchess 12 RESIDENCEA. New York B Dutchess
(STATE) (COUNTY) (STATE) (COUNTY)
C. CHECK ONE 0 CITY 1!1 TOWN 0 VILLAGE C. CHECK ONE 0 CITY r"! TOWN 0 VILLAGE
~~~CIFY Wappinger ~~~CIFY Wappinger
D. STREET ADDRESS 26 Lakeside Drive ZIP 12590 D. STREET ADDRESS 26 Lakeside Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES t1' NO
07 / 08 / 1976 13. A. AGE 27 3B. DATE OF BIRTH 10 /25 /1979
MONTH DAY YEAR MONTH DAY YEAR
3. A. AGE 30
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Contractor
B. TYPE OF INDUSTRY OR BUSINESS A A A Chimney
5. PLACEOFBIRTH Peekskill, New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME William Edward Mancusi. Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Colleen Marie Komlos
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
o
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Manhattan, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Joseph Peter Rosi
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Rosemary Elizabeth Piscitelli
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL AtlNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END?
(2) 0 DEATH
2005 '
B. HOW 010 LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / ~
MONTH DAY YEAR
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
YEAR
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2ND
3RD
4TH
DATE
by New York Domestic
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25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
YEAR MONTH DAY YEAR
DATE 06/20/200
appinger Falls, NY 12590
CITYITOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
28. PLACE WHERE MARRIAGE OCCUR~ I J
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
ZIP
AM
02:23pM
06 21 2007 08 19 2007
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
1~IL
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ZIP
WITNESS TO C~MONY
NAME (PRINT) C
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