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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Charles John Antonucci. Jr.
FIRST MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
"I
COUNTY Dutchess
CITYffOWN Wappinqer
~~':k~ 1368 .
~5~1:~R 102
SUPPLEMENTAL FILE
FROM THE BRIDE
Lisa Ann Malecki
MIDDLE CURRENT SURNAME
~
Lo
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAMEAFTERMARRIAGE Antonucci
(OPTIONAL-SEE REVERSE) 046-80-7901
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A, New York B. Dutchess
(STATE) (COUmY)
C. CHECK ONE 0 CITY r::! TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 6 Carnaby St. Apt D ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 6 NO
13.A. AGE 24 3B.DATEOFBIRTH 11 /17 /1'981
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Lie. Veterinary Technician
B. TYPE OF INDUSTRY OR BUSINESS N. Westchester Vet.
15. PLACE OF BIRTH New Britain, Connecticut
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Tadeusz Malecki
'B. COUNTRY OF BIRTH Poland
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 115 62 81 08
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUmY)
C. CHECK ONE 0 CITY r!f TOWN 0 VILLAGE
~~~CIFY WappinQer
D. STREET ADDRESS 6 Carnaby St. Apt D
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
07 / 14 / 1978
MONTH DAY YEAR
3. A. AGE 28
3B. DATE OF BiRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Construction IReal Estate
B. TYPE OF INDUSTRY OR BUSINESS Self-employed
5. PLACE OF BIRTH Staten Island, New York
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Charles John Antonucci, Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Karen Louise Paine
B. COUNTRY OF BIRTH Japan
8. NUMBER OF THIS MARF,lIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
17. MOTHER
A. MAIDEN NAME Anna Frank
B. COUNTRY OF BIRTH Germany
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL AN'(YLMENT
DEQTH
DEATH
o
B. HOW 010 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
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (ClTYlCOUmY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. --- 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
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (ClTYlCOUmY. STATElCOUNTRY. IF NOT USA) saF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say
as to my right to enter Into the m
21. SIGNATURE OF GROOM~
D.
o
o
1ST
2ND
3RD
4TH
the information I provided is tru
o
o
o
23. SUBSCRIBED AND SWORN TO/AFFIRM
SIGNATURE OF TOWN OR CITY CLE
This license authorizes the rriage in New York State of the bride and groom named above by any person authorized
Relatipns 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 onl for .the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITYJCl,I;RK C M t 25 A SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) onn . as erson . .
{SEAL} SIGNATURE ~ .
MAI~ tm
'-.,..I
DATE
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
YEAR
MONTH
DAY
YEAR
09
18 2006
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON TH
DATE AND AT THE TIME AN
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. couNTf)'f't"~ II f.t.JI
C. LOCATION OF CEREMONY
(CHECK ONE ANp SPECIFY)
o CITY OF IIITOWN OF 0 VILLAGE OF
SPECIFY C\ ~ h..r/-l.A:: / c- '-
29. OFFICIANT
NAME (PRINT)
SIGNATURE~
OOH-98 (0312006)
ZIP
31. WITNESS TO C1Y~MONY I
NAME (PRINT) ~l h Ii Cd
SIGNATURE~
5
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