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STATE ALE .....,..
(THIS SPACE RlR STAlE USE ONLY)
I
1. A.
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FULL NAME ~rd.1 Va..
QJRREIllTSllRI\lNllE
COUNTY Dutchess
CITY/TOWN \Napplnger
~~::fF;'" 1~
~G~li~R 54
~
L 0 SUPPLEMENTAL RLE
FROM THE BRIDE
FU\.L NAME U5&~alie Gill~
11. A.
CURRENT SURNAME
..
N
B. BlRlll NAME \MAIDBl lWEI, IF IJIfA:REHT
C. SURNAME AfTER t.WlRlAGE VargllS
(OPTIONAl. SEE REVERsm-1 . ""n I'Y'>ftft
D. SOGlALSECURllYNUMIlER _ ~-nn-~
12. RESlDENCEA.NqM,,~a:k B.~I
C. CHECK ONE 0 CITY i!l TOWN 0 VlU.AGE
AND ..&- .
SPECIFY v~A'lnger
D. STREETAODRESS15 R~ds Wt!JtI ZF,125M
E. IS RESIDENCE WITHIN UMlTS OF CITY OIllNCOllFOllAlBl VILlAGa 0 1IEiS~ f<<)
13. A. AGE22 3B.DATEOFBlR1H~ 'Y ~
14. EMPLOYMENT
A. USUAl OCCIJPAl1ON Domestic" Engineer
a. TYPE OF INDUSTRY OR 8USR\IESS
15. PLACE OFBlR1H~~l..
16. FATHER
A. NAMECbades Wlliam Gilleo
B. COUNTRYOF8lRll41 SA
17. MOlliER
A. MAlDEN NAME Sara Emma DeMilio
B. COUNTRY OF B1RTtt J S A
18. NUMBER OF llilS MARRIAGE 1
19. ~R~U~~~ MARRlAGESWHlCH ENDED BY
DIVORCE ClI/IL ANNUlMENT
o 0
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)1_ -011
D. SOCIAL SECURITY NUMBER _~___8
2. RESIDENCE A. ~.xor:k B.~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND Ul&- .
SPECIFY v_ppnger
D. STREETAODRESS 15 R~ds Wf!tI ZIP 125M
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VlUAGE? 0 YES ~ NO
3. A. AGE 23 3B. DATE OF BIRTH Jg / ~'l / 1aB3-
4. EMPLOYMENT
A. USUAL OCCUPATION MeJCbandse Handler
B. TYPE OF INDUSTRY OR BUSINESS Gap 100
5. PLACE OF BIRTH ~'tE~Y.USA)
6. FATHER
A. NAME John Vai:gllS
B. COUNTRY OF BIRTH t) S A
7. MOTHER
A. MAIDEN NAME Jlldy Anna Pallotta
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE ' CIVIL ANNULMENT
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEAlH B. HOW OlD lAST MARRIAGE 8M (3l 0 D1VOIlCE IS) 0 MNllI.UENT (2) 0 Dalll
C. DATE LAST MARRIAGE ENDED? / / C. DATELASTUARRlAGE9lDEDY / /
MONTH DAY YEAR MONTH DAY \'EAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO O. ARE ANY FORMER SPOUSE(S) Al.J\IE? D.'l'ES 0 He
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVlOUSLV DIVORCED OR ANNUIJ.ED, PROVIDE 1HE FOU.OWING INR)RMA110N
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DEGREE Pl.AGe ISSUED AGNNSTWHOM
(MONTll, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE (M0Nl1i, DAY, YEAR) \CI1VJGOUNlY.S1l\TEA:lOlJNlRV.lFNOT~ SlELFSPOUSE
1ST 0 0 1ST 0 0
2ND 0 0 2ND D 0
3RD 0 0 SAD 0 0
4TH 0 0 4TH 'D 0
I duly swe!lr/affirm, depDse an~d say that tD t Y knDWI~.dge,a. I!l;lndjlslief that the information I pmvideI:I is t.,and that I decl~athaJ no legal impediment exists
as to my nght to enter mtD the m ag tate. /~ - JI!
. ( /
21. SIGNATURE OF GROOM ~ . RE OF 8R1DE~ - - .
rtSl?' RR USE NAME
23. ~::~~~~DO~N,.oo~OJ': d;W6r:r~E~ BEFOR DAle 05I1Q12OO6
This license authorizes the marriage in New York State of the bride and groom named above by any person authori2lell by New York Domestic
Relations Law !ill to perform marriage ceremonies within New Yo State. THIS LICENSE VAUD IN NEW YORK STAlE ONLY.
o If checked, this license is to be used only for the purpose of a second or ClllI8RlOIlY.
24. TOWN OR CITY CLERK 25. A. sou:MNlZAnOlll PallOO BEGINS
~
{ SEAL }
'-v-I
NAME (PRINT)
TIME
MONTH
10:52 :: 05
ZIP
1~
28. PlACE WHERE MARRIAGE OCCU.. .' R~
A. STATE NEW YORK 8. COUNTY dJqifCf1:&&
SIGNATURE ~
MAILING A
II
STREET
30. WITNESS TO CEREMON
NAME (PRINT) ~ .s e.Oc n LOl r~ 0 V1
SIGNATURE~~ ~
DOH.98 (07/2005)
C. lOCAnOlll OF CEREMONY
(CHECK 'ONE AND SPECIFY) . /'
o 'CITY OF 0 TOWN OF~IUAGE OF
SPECIFY WU!'~ ~
NAME (PRINT)
SIGNATURE~