127
I
STATE FfLE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Andrew Charles Galeno
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinqer
~~~~~c: 1368 .
~~~I~~~R 127
.-J
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Laura Marie Picorelli
MIDDLE CURRENT SURNAME
11. A. FULL NAME
1 . A. FULL NAME
FIRST
FIRST
ll.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Galeno
(OPTIONAL' SEE REVERSE) 088-60-5611
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY [)" TOWN D VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 51 D Sherwood Forest
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 120-54-4818
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~~CIFY Beekman
D STREET ADDRESS 57 Susan Drive
+
ZIP 12590
YES d' NO
,;1975
YEAR
12570
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
01 / 24 / 1971
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D
06 /22
DAY
13.A. AGE 31
3. A. AGE 35
3B. DATE OF BIRTH
3B. DATE OF BIRTH
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Mortgages
B. TYPE OF INDUSTRY OR BUSINESS Mortgage IT
15. PLACE OF BIRTH Poughkeepsie, New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Robert Joseph Picorelli
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Katherine Mary Ciringione
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
4. EMPLOYMENT
A. USUAL OCCUPATION Self-employed
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH Queens, New York
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Michael A. Galeno
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Katherine A. Cuneo
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
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(3) D ANNULMENT (2) D DEATH
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(3) D DIVORCE
(2) D DEATH
(3) D ANNULMENT
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B. HOW DID LAST MARRIAGE END?
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
~
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATIE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (C~TY/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, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
D D
D D
D D
D D
diment~ists
1ST
2ND
3RD
4TH
at the information I provided i
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say,
as to my right to enter into the ma
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21. SIGNATURE OF GROOM ~
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YEAR
STATE
27. TYPE OF CEREMONY
o Jg" RELIGIOUS
9 D OTHER, SPECIFY
CITY /TOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
AM
;: 017 0
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY D v TGH~>:
1 D CIVIL
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF D TOWN OF 2fVILLAGE OF
SPECIFY p;'f tv '- r /1/ t-
NAME (PRINT)
SIGNATURE~
SIGNATURE~
DOH-98 (03/2006)