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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Adam Anthon~ Casullo
MIDDLE CURRENT SURNAME
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is t
as to my right to enter into the m a state.
21. SIGNATURE OF GROO~~ 22. SIGNATURE OF BRIDE~'
'. . -. USE
23. SUBSCRIBED AND SWORN OIAFFIRMED ilEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ . DATE
This license authorizes the marriage in New State of the bride and groom named above by any person authorized by New York Dom
Relations Law ~11 to perform marriage ceremonies within New York State. 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) John C. Masterson
TIME MONTH YEAR MONTH
SEAL SIGNATURE ~. DATE
MA~~G~fcfaT~ AM 15 2007 05 13 20C
'-v-I STREET 06:07 PM 03
I CERTIFY THAT I SOLEMNIZED 28. PLACE WHERE MARRIAGE OCCURRED
THE MARRIAGE OF THE PER- --:J"} _
g~~~ ~~E;:T A:H~V~I~ 1~6 A. STATE NEW YORK B. COU~
PLACE INDICATED.
~ C. LOCATION OF CEREMONY
29. OFFICIA '..u ZCHE ONE AND SPECIFY)
NAME (PRINT) ,."
CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY ct--6~ tt-FsJ!t& J1
COUNTY Dutchess
CITYfTOWN Wappinger
~~~::f~ 1368 .
~~~I~~~R 17
1. A. FULL NAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)082 66 4116
D. SOCiAl SECURITY NUMBER --
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE ItJ CITY 0 TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 5 L vnbrook Road ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 1!1 YES 0 NO
3. A. AGE ~ 1 3B. DATE OF BIRTH 02 / 15 / 1976
MONTH DAY YEAR
...
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4. EMPLOYMENT
A. USUAL OCCUPATION Bartender
B. TYPE OF INDUSTRY OR BUSINESS Restaurant
5. PLACE OF BIRTH Bronxville. New York
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Adam Anthony Casullo
B. COUNTRY OF BIRTH Italy
7. MOTHER
A. MAIDEN NAME Teresa Anne Branca
B. COUNTRY OF BIRTH U.S.A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Carrie Ann Decker
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Casullo
(OPTIONAL. SEE REVERSE) 118-74-1799
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATjO) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~CIFY PouQhkeepsie
D. STREET ADDRESS 5 Lynbrook Road ZIP 1260
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6. YES [
12 /28 . A9
MONTH DAY YI
13. A. AGE 28
3B. DATE OF BIRTH
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
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14. EMPLOYMENT
A. USUAL OCCUPATION Clerk
B. TYPE OF INDUSTRY OR BUSINESS Government
15. PLACE OF BIRTH Rhinebeck. New York
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Russell George Decker
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Kathleen Marie Gannon
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEI
(
(3) 0 ANNULMENT (2) 0
/ /
,'- YEAR
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
..
2D. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORI
DATE OF DECREE PLACE ISSUED AGAINST'
(MONTH, DAY. YEAR) (CITYICOUNTY. STATElCOUNTRY. IF NOT USA) SELF SP'
SIGNATURE~
DOH-96 (D3I2006)
NAME (PRINT)
SIGNATURE~
~r