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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~~ 1368 '
~5~~~R 1 05
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Eric Robert Lutz
MIDDLE CURRENT SURNAME
tilAlt:. t'1~ NUMI5IC"
(THIS SPACE FOR STA TE USE ONL Y)
SUPPLEMENTAL FILE
FROM THE BRIDE
Priscilla Ann Fassacesia
MIDDLE CURRENT SURNAME
-.J
Lo
1 , A, FULL NAME
11. A. FULL NAME
FIRST
FIRST
B, BIRTH NAME, IF DIFFERENT
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE Lutz
(OPTIONAL. SEE REVERSE) 1 05-70-3350
D. SOCIAL SECURITY NUMBER
12, RESIDENCE A. New York B, Dutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY r::! TOWN 0 VILLAGE
~~~CIFY Fishkill
0, STREET ADDRESS 15 Larch Court ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES d NO
13, A, AGE 25 3B, DATE OF BIRTH 10 /01 /1980
MONTH DAY YEAR
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 128-62 7649
D, SOCIAL SECURITY NUMBER -
2, RESIDENCE A. New York B, Dutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY r!l' TOWN 0 VILLAGE
~~~CIFY Fishkill
D, STREET ADDRESS 15 Larch Court
ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES d NO
09 / 18 / 197
MONTH DAY YEAR
3. A. AGE 26
3B. DATE OF BiRTH
14. EMPLOYMENT
A, USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS P. V. S. C. D.
15, PLACE OF BIRTH Bronx, New York
(CITY, STATE I COUNTRY IF NOT USA)
16, FATHER
A. NAME Rocco Joseph Fassacesia
. B, COUNTRY OF BIRTH USA
17. MOTHER
A, MAIDEN NAME JoAnne Glennon
B, COUNTRY OF BIRTH USA
1
1 B, NUMBER OF THIS MARRIAGE
19, PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL AN~LMENT
D~H
4. EMPLOYMENT
A. USUAL OCCUPATION EnQineer
B. TYPE OF INDUSTRY OR BUSINESS I. B. M.
5. PLACEOFBIRTH Manhattan. New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A, NAME Robert Alfred Lutz
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Maria Paula Testa
B. COUNTRY OF BIRTH U S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVOBCE CIVIL ANN~LMENT
DEyr
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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.,.- YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
OATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, 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) (CrTYICOUNTY. STATEICOUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
no legal impediment exists
~'
~
:J
Z
Q
Z
C
~
~
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose and say, that to the bes y knowledge and belief that the information I provided;11's t ahd that I declare th
as to my right to enter into the )TlalTJ.age S te.
21. SIGNATURE OF GROOM ~ ~ 22. NATURE OF BRIDE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME E CU E NAM USE CURRENT NAME 07/21/2006
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of e bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New Yo tate. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be us only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY RK 25. A. SOLEMNIZATION PERIOD BEGINS
n
~
{ } NAME (PRINT)
SEAL SIGNATURE'
MAIL<IUI:!
"-v-I ~\J.
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
TIME
MONTH
YEAR
MONTH
i~,,"~ 07/21/200
. - DATE
t)~nRd, Wappinger Falls, NY 12590
02:1~~
07
22
2006
09
19 2006
ZIP
ATE
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 b OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY R~ ~
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY Cp. r-",^-"" \
\
1 0 CIVIL
TITLE
rn~
'c