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COUNTY Dutchess
CITYrrOWN Wappinger
~~~~~c; 1368 .
~G~~~~R 38
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mark Anthon~ Perillo
MIDDLE CURRENT SURNAME
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
I
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Elizabeth Mary Jones
MIDDLE CURRENT SURNAME
--.J
1. A. FUll NAME
11. A. FUll NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl- SEE REVERSE) 092-74-5245
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY lY TOWN 0 VILLAGE
~~~CIFY Wappinger
o STREET ADDRESS 32 Robert Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES rf NO
3. A. AGE 37 3B. DATE OF BiRTH 01 / 17 / 197
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 093-74-6402
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE) . (COUNTY)
C. CHECK ONE 0 CITY []I TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 32 Robert Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES r1 'NO
13. A. AGE 33 3B. DATE OF BIRTH 06 / 19 /1973
MONTH DAY YEAR
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Receptionist
B. TYPE OF INDUSTRY OR BUSINESS Veterinary
15. PLACE OF BIRTH Yonkers, New York
(CITY, STATE I COUNTRY IF NOT USA)
A. USUAL OCCUPATION Computer Repair
B. TYPE OF INDUSTRY OABUSINESS Computers
5. PLACE OF BIRTH Bronx, New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME John Jones
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Maria Garcia
B. COUNTRY OF BIRTH Cuba
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
6. FATHER
A. NAME Anthony David Perillo
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Theresa Lucy Stisi
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
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. - YEAR
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, OAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, depose 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 th~ amage state. ~
.' Y"f\ ~
21. SIGNATURE OF GROOM "'. . SIGNAT E OF BRIDE'-. 7.-:::::::::>
USE CURR NT USE CURRENT NAME
23. ~~':~~~~Do~N-:b~~06':T cr~~E~BEFOREME DATE 05/17/2007
This license authorizes the marriage in New York State of the by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York Stat 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Joh C. Masterson
{ SEAL SIGNATURE~ C DATE 05/17/200 TIME MONTH YEAR MONTH
'-- .-J MAIL~n~rtf&1eb h Rd, ppinger Falls, NY 12590 AM 05 18 2007 07 16 2007
-v- 01:1 ij,M
STREET CITYITOWN STATE ZIP
~~~R~~Ri~~~ 10~O~~N:,zEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. AY YEAR 0 !B-m:LIGIOUS
DATE AND AT THE TIME AND / 3 AM J:.
PLACE INDICATED. 0 P :J}o 0 f 9 0 OTHER, SPECIFY
SHARRN
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 'D-... n~
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF~WN OF ~J:AGE OF
"J f'l^ . I qL. OJ:::> r-... ' lr<
~, M,,, 1l..-f~ r nl V I
SPECIFY
WD. pp Irj -e r
~