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COUNTY Dutchess
CITYrrOWN Wappinger
~~~~kc: 1368
~5~liJ~R 83
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thom::!!': D'iorio
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Tar;:J .JA;:Jn H;:J~AS
MIDDLE CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
8. 81RTt! NAME, IF DiFFERENT 8. 81RTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE D'iorio
(OPTIONAL - SEE REVERSE) 064 78 1677 (OPTIONAL. SEE REVERSE) 123 72 4663
D. SOCIAL SECURITY NUMBER __ - __ - _ D. SOCIAL SECURITY NUMBER --
2. RESIDENCEA. ConnAdir.llt B. H;:Jrtforrl 12. RESIDENCE A. NAW York B. Dutchess
(STATE) (COUNTY) (STATE) (COUNTY)
C. CHECK ONE 0 CITY Elt TOWN 0 VILLAGE C. CHECK ONE 0 CITY iY TOWN 0 VILLAGE
~~~CIFY Burlington ~~~CIFY Wapoinger
D. STREET ADDRESS 51 Davis Road ZIP 06013 D. STREET ADDRESS 44 Tor Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES c1 NO
3. A. AGE ?7 3B. DATE OF BIRTH 05 / 28 / 1979 13. A. AGE 26 3B. DATE OF BIRTH 03 /26 /1980
MONTH DAY YEAR MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Sports Ticker
8. TYPE OF INDUSTRY OR BUSINESS PA Sport
5. PLACE OF BIRTH Pouahkeeosie. New York
(CITY, STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Wappinger Cntrl. Schl.
15. PLACE OF BIRTH Cold Sprino, l'iIew York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME William Michael Hayes
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Lou Ann Francies
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
6. FATHER
A. NAME Joseoh A. D'iorio
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Gloria B. Molle
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
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
13) 0 ANNULMENT
/ /
(2) 0 DEATH
(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) (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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and sa
as to my right to enter into the
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1ST
2ND
3RD
~
USEC
23. SUBSCRIBED AND SWORN TO/AFFiRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perlorm marriage 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 CITYJCU=RK C M t 25 A SOLEMNIZATION PERIOD BEGINS
onn . as erson . .
NAME (PRINT)
21. SIGNATURE OF GROOM~
by New York Domestic
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25.8. SOLEMNIZATION PERIOD
ENOS AT MIDNIGHT ON:
r-"'-..
{ SEAL }
'-y-I
MONTH
DAY
YEAR
TIME
MONTH
YEAR
06/28/200
DATE
sh Rd, Wappinger Falls, NY 12590
SIGNATURE ~
MAIL~ "reRffi:!
08
27 2006
12:5S;~
06
29
2006
ZiP
CITYITOWN STATE
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. AY YEAR 0 IJ"'RELlGIOUS
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 ktcl')fS5
10 CIVIL
01. Og,JOOb 90 OTHER, SPECIFY
TITLE QN\A.N\ (lo..4-t'blit. ~
DATE rl.\..\'1 8f ~oo<c
Ne.1..V P~r.c I t2 S- 3 3
STATE ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) -rA i-VI F' i '^
,
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY fASl" FI~,", ~ '\ \...l,..
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i= MAILING AD ESS
a::w "? 0, 001: 4-.18 I
STREET
o 30. WITNESS TO CEREMONY
II.
l-+cpe.we.. :::ru f\C-n lyrJ
CITY/TOWN
NAME (PRINT)
SIGNATURE~
SIGNATURE~
",t""I.l.J no tnI') 1f\I'V\C\