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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~~ 1368
~G~liJ~R 1 84
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael William Girvalo
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Heather Joyce Gorey
MIDDLE CURRENT SURNAME
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 116 66-3844
D. SOCIAL SECURITY NUMBER -
2 RESIDENCE A. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY tJ TOWN 0 VILLAGE
~~~CIFY Pouahkeeosie
D. STREET ADDRESS 2879 Route 9d ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES tj NO
3. A. AGE 28 3B. DATE OF BiRTH 03 /03 / 1978
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Girvalo
(OPTIONAL. SEE REVERSE) 064-64-2431
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r!'1 TOWN 0 VILLAGE
~~~CIFY PouQhkeepsie
D. STREET ADDREss2879 Route 9d ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES tJ NO
13. A. AGE 26 3B. DATE OF BIRTH 02 /28 ,%980
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Service Technician
B. TYPE OF INDUSTRY OR BUSINESS Cablevision
5. PLACE OF BIRTH Pouahkeeosie, New York
(CITY, STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Office Manaaer
B. TYPE OF INDUSTRY OR BUSINESS Service Master
15. PLACE OF BIRTH Carmel, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Stephen Richard Gorey
'B. COUNTRY OF BIRTHU SA
17. MOTHER
A. MAIDEN NAME Carol Ann Travis
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
6. FATHER
A. NAME Michael W. Girvalo
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Carolyn T. Diloreto
B. COUNTRY OF BIRTIH 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
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
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, 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 . .J:f"1 0 4TH , 0 0
I duly swear/affirm, dep.ose and sa, y, that to~t0es" ' f "r)<06wlEj(lge ~[Ia belief that the information I provided is truta.nd tha~ I d, ec~are. th~~o Ie. gal impediment exists
as to my right to enter intp the }J'Iarnage ate!./.,,, I " J,/ rrr..' i
21. SIGNATURE OF GROOM;->U ' ," / / 22. SIGNATURE OF BRIDE'-= /f a...'+::IIi..;... J C{~l LVt/
us NAM I USE CURRENT NAME / i
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME "-'-, ' DAT'f// 1;e. /13/2006
SIGNATURE OF TOWN OR CITY CLERK" .
This license authorizes the marriage in New k State 0 'he bride and groom named above by any person authorized by eV!)York Domestic
Relations Law ~11 to perform marriagB 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) Jo/ hn C. Mastel;1on
{TIME MONTH YEAR MONTH
SEAL SIGNATURE" . --. DATE 12/13/2006
I...-.-J MAIj..J~G.ADDI)~E;$S.lu'sh Rd, AM 12 14 2006 02 112007
-v- LU MIOOIEW appinger Falls, NY 12590 05:29PM
STREET CITYrrOWN STATE ZIP
~~~R~~R;~~J IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
YEAR
CIVIL
28. PLACE WHERE MARRIAGE OCCU~
A. STATE NEW YORK B. COUNTY cbIc.{J'(:lk.~
C. LOCATION OF CEREMONY
(CHE~NE AND SPECIFY)
~TY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY ---F6 "'- ~ M- ~ ft.'; S J-L
NAME (PRINT)
SIGNATURE"