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couNTYDutchess
CITYrrOWN WappinQer
~~':~1368 .
~5~I:l~R4 7
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Justin Michael Letizia
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Rob~n Michele Foreman
FIRST MIDDLE CURRENT SURNAME
~
1, A, FULL NAME
11. A. FULL NAME
FIRST
..
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Letizia
(OPTIONAL- SEE REVERSEb81_72_3978
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANew York B.Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY -tJ TOWN 0 VILLAGE
~~~CIFYWappinQer
D. STREETADDRE~6C Alpine Drive ZIp12590
E. IS RESIDENCE wrrHIN UMrrs OF CITY OR INCORPORATED VILLAGE? 0 YES~ NO
/15 7978
DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEb88 68 8422
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 ClfYlItJ TOWN 0 VILLAGE
~~~CIFY Waooinaer
D. STREET ADDRESS26C Alpine Drive ZIP 12590
E. IS RESIDENCE WITHIN UMrrs OF CITY OR INCORPORATED VILLAGE? 0 YES"'D NO
03 /25 /1980
MONTH DAY YEAR
3B. DATE OF BIRTH
06
MONTH
13. A. AGE28
3. A. AGr:27
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Athletic Trainer
B. TYPE OF INDUSTRY OR BUSINESS Putnman Phys. Med.
s. PLACE OF BIRTHEnQlewood Cliffs, New Jersey
(CITY, STATE I COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATIONUnemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTHYoungstown, Ohio
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMEJames Harry Foreman, Jr.
'B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAME Marilyn Irene Pettitt
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 1
6. FATHER
A. NAME Anthonv Letizia
B. COUNTRY OF BIRTH USA
7. MOTHER .
A. MAIDEN NAME AnQela Tamburri
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVfOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DOATH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) o ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID I:AST MARRIAGE END? (3) 0 DIVORCE '(3) CI ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?' ......L /
MONTH DAY" . - YEAR
D. ARE ANY FORMER SPOUSE(S) AUVE? 0 YES 0 NO
..
20. IF PREVIOUSLY DIVORCED OR ANNUI,I"EE), PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
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
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, aep'0S8 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 mama estate. ~ (j . ~
21. SIGNATURE OF GROOM~,rI\ NATURE OF BRIDE~ ~.~
USE CU RE USE C~ NAME 06/11/2007
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State 01 by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York tate. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o II checked, this license is to be used only for the purpose 01 a second or subsequent ceremony.
~ 24. TOWN OR CrrYJ <iLER~ M t 25: A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) onn \J. as erson
{SEAL } SIGNATURE~ ~ C. DATE 06/11/2007
'-v-' M~1\ffl~bu Rd, W ppinger Falls, NY 12590 01 :23 :~ 06
STREET CITYITOWN STATE
~~~~~RT~~lIO~~~N~:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TI EM. AY YEAR 00 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SP
TIME
MONTH
MONTH
YEAR
YEAR
12
2007
08
10 2007
ZIP
1~
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~
C. LOCATION OF CEREMONY .
(CHECK ONE AND SPEC
o CITY OF OWN OF 0 VILLA E OF
SPECI
NAME (PRINT).
SIGNATURE~ '
DOH-98 (0312006)
NAME (PRINT)
SIGNATURE~