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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Joseph Louis Francis Suriano - Schara
FIRST MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~; 1368
~~~I~;~R 39
1 . A. FULL NAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 067 72-9491
D. SOCIAL SECURITY NUMBER -
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 1!1 VILLAGE
~~~CIFY Wappinqers Falls
D. STREET ADDRESS 66 I mperial Blvd., Apt. 230~IP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? rf YES 0 NO
3. A. AGE 21 3B. DATE OF BIRTH 07 / 18 / 1985
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Gymnastics Instructor
B. TYPE OF INDUSTRY OR BUSINESS Diamond Gymnastics
5. PLACE OF BIRTH Pouqhkeepsie, New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Joseph L. Schara
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Theresa Josephine Suriano
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
10. 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
I
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Christina Marie Peterson
MIDDLE CURRENT SURNAME
~
1 1. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Suriano - Schara
(OPTIONAL - SEE REVERSE) 099-72-7356
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r! TOWN 0 VILLAGE
~~~CIFY East Fishkill
D. STREET ADDRESS 85 Carol Drive ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d "NO
06 /22 /1987
DAY YEAR
13. A. AGE 19
3B. DATE OF BIRTH
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Kitchen Help
B. TYPE OF INDUSTRY OR BUSINESS Lodge Works
15. PLACE OF BIRTH Carmel, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Eric Peterson
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Donna Settembrini
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
De.crH
B. HOW DID 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
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
knowledge and belief that the information I provided is true fnd th
o 0
o 0
o 0
o 0
that no legal impediment exists
23. SUBSCRIBED AND SWORN T ME BEFORE ME OS/22/2007
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of t nd groom named above by any person authorized by New York Domestic
Relations Law !Ill to perform marriage ceremonies within New York te. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o " checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) J 0 h
{ OS/22/200 TIME MONTH YEAR MONTH DAY YEAR
SEAL SIGNATURE ~
'- -J MAIt~t'H8mfd~ 12590 AM 05 23 2007 07 21 2007
-v- 02:22pM
STREET
1 CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
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USE CURRENT
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
ZIP
1~IVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~LL~ \u ~S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF"llrTOWN OF 0 VILLAGE OF
SPECIFY"\ J.)l1.fP; J~ r
Z
31. WITNESS TO CEREMONY
NAME (PRINT) 'U e C'J...i\ W~~C
SIGNATURE~ ~ 1-^)pf~