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COUNTY Dutchess
CITYITOWN Wappinger
~~~~~ 1368 '
~~~I~~~R 33
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert Martin Sivco
MIDDLE CURRENT SURNAME
I
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Tiff~I~~E Lee Lacoc~~~t~ SURNAME
-1
L A. FUUL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 057-72-6369
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. Np.w York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY IJt TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 16 Blackthorn Loop ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Cl'" NO
3. A. AGE ?R 3B. DATE OF BiRTH 09 / 15 / 197
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Sivco
(OPTIONAL. SEE REVERSE) 079 68 5096
D. SOCIAL SECURITY NUMBER --
12. RESIDENCEA. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY [)I" TOWN 0 VILLAGE
~~~CIFY Hvde Park
D. STREET ADDRESS 107 East Market Street; Ap~,P
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
11 /11
MONTH DAY
12538
YES ~o
/1980
YEAR
13. A. AGE 26
3B. DATE OF BIRTH
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS Marist College
15. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard M. Lacouette
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Lee Ann Romano
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
A. USUAL OCCUPATION Technician
B. TYPE OF INDUSTRY OR BUSINESS Communications
5. PLACEOFBIRTH Yonkers. New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Robert T Sivco
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Barbara M. Avezzano
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 (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
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
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
w
en
z
w
(,)
::::i
1ST fJ 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm,dep.oseand 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 ma~age state. . .if J
21. SIGNATURE OF GROOM~ -){ ~~ 22. SIGNATURE OF BRIDE~. OlJ ttw:f ~~~
23. SUBSCRIBED.AND SWORN TO/AFFIRMED BEFORE ~iE -; i U CURR NAME 05/07/2007
SIGNATURE OF TOWN ORCIl)' CLERK ~ _.'c' .~.. DATE
This license authorizes the ma,piage in NewY~' State of t e bride and groom named above by any person authorized by New York Domestic
Relations Law~11 to perform marnage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
!i'lf checked, this license is to be used only for the purpose of a second or subsequent ceremony,
~ 24,rOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ . .}. . NAME (PRINT) John C. Mas erson TIME MONTH YEAR MONTH
SEAL. SIGNATURE ~ DATE
'- -.J MAILI~~A~rdS AM 05 07 2007 07 05 2007
-v- STREET 02:3PM
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~ I ~q:
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
SPECI~\. J~ r
~L
o
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) ~ \ f t \ L Le...r\ t---
SIGNATURE~ ~ ,p I U lr-----=""