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COUNTY Dutchess
CITYITOWN Wappinger
~~~:~~ 1368 .
~~~liJ~R 129
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Vincent Anthony Berchielli
MIDDLE CURRENT SURNAME
I
STATE F1t:E NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
SUPPLEMENTAL FILE
FROM THE BRIDE
Patricia Janett Morales
MIDDLE CURRENT SURNAME
.-J
Lo
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0..
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Berchielli
(OPTIONAL - SEE REVERSE) 124-90-0912
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE).J (COUNTY)
C. CHECK ONE 0 CITY LJ TOWN 0 VILLAGE
AND W .
SPECIFY ap(:1lnger
D. STREET ADDRESS 8 Alpine Drive Apt. t- ZIP 1259U
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
04 /25 /1972
DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 069-64-9379
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r!5 TOWN 0 VILLAGE
~~~CIFY WappinQer
D. STREET ADDRESS 8 Alpine Drive Apt. F
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d' NO
04 / 26 / 197
MONTH DAY YEAR
13. A. AGE 34
3. A. AGE 34
3B. DATE OF BIRTH
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Software Developer
B. TYPE OF INDUSTRY ORBUSINESS Epicor / CRS
5. PLACE OF BIRTH Huntington. New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Arthur James Berchielli
B. COUNTRY OF BIRTH USA
14. EMPLOYMENT
A. USUAL OCCUPATION Network Engineer
B. TYPE OF INDUSTRY OR BUSINESl? Savvy Networks
15. PLACE OF BIRTH La Paz, BOlivia
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Jose Alfonso Morales
'B. COUNTRY OF BIRTH BoliVia
17. MOTHER
A. MAIDEN NAME Mary Luz Arancibia
B. COUNTRY OF BIRTH BoliVia
1
18. NUMBER OF THIS MARRIAGE
7. MOTHER
A. MAIDEN NAME Naomi Anne Walls
B. COUNTRY OF BIRTH USA
1
8. NUMBER OF THIS MARF,lIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL AN't)'LMENT
D~H
DEAbH
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. DAY. YEAR) (CITYICOUNTY. STATEICOUNTRY, 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 WIHOM
(MONTH, DAY, YEAR) (CIJY/COUNTY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
o
o
o
1ST
2ND
3RD
o
o
o
o
o
o
USE CURRENT NAME
~
08/22/2006
DATE
by New Yor!< Domestic
DATE 08/22/200
inger Falls, NY 12590
TIME
MONTH
YEAR MONTH
YEAR
01:4~~
08 23 2006 10 21 2006
STATE
27. TYPE OF CEREMONY
o Q( RELIGIOUS
9 0 OTHER, SPECIFY
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY D"l.7l:tf'iE.<;5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF QI( TOWN OF 0 VILLAGE OF
SPECIFY f3i+.s (' F;.5 fH~./ L L-
10 CIVIL
T1TLEClfrIfoLIC 'tItS"
CJ II (, / z, ~() b
IV IZ Sf'
DATE
!+oftwfl..U J~tJc n(),)
CITYITOWN
"'. W"""" '" 'f""' []..
NAME (PRINT) A-rT"HevJ clJ.C.HiELL'
SIGNATURE~ ~ ~~/('"
OOH-98 (0312006)
STATE
f)tel/t..c5
NAME (PRINT)
SIGNATURE~