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COUNTY putchess
CITYfTOWN WaDDinaer
~~~ 1368
~5~~R 50
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
r-
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
"I
.-J
L 0 SUPPLEMENTAL FILE
..
I'l
1. A. FULL NAME ~"y .Inhn tg;<<n
B. BIRTH NANE, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
D. =~I~=RSE) 101-58-4681
2. RESIDENCE A. N!I:i)lll Yoft B. nutr.ha~~
~ (COUNlY)
c. CHECK ONE 0 CITY I!!! TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 328 Old Hopewell Road Z1~ 12590
E. IS RESlOENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE? 0 YES ~ NO
3. A. AGE 44 3B. DATE OF BIRTH n~ /17 / 1961
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION [lrivar
B. TYPE OF INDUSTRY OR BUSINESS 0 Bertoline & Sons
5. PLACE OF BIRTH Mount Kisco. New York
(CITY. STATE I COUN11'lY IF NOT USA)
6. FATHER
A. NAME Victor Jo,p-ph V nTl'n
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME C':ecelia Catherine Ludwia
a COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
FROM THE BRIDE
11. A. FULL NAME Barbara Rose Panetta
FIRST MIODLE
B. BIFml NAME (MAIDEN NAME). IF DIFFERENT Panetta
C. SURNAME AFTER MARRIAGE Panetta - yozzo
(OPTIONAL. SEE REVERSE) 079-54-2135
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) -' (COUNlY)
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 328 Old Hopewell Road
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE?
13. A. AGE 45 3B. DATE OF BIRTH 01 ""9
MONTH DAY
CURRENT SURNAME
CURRENT SURNAME
Z1~ 1 i!~!:IU
.,
o YES 0 NO
1!61
YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION student
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Bronx. New York
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Arthur J. Panetta
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Nonna Dimichino
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES. 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DlVORCECML ANNULMENT DEATH DIV10RCE CIVIL AN~LMENT
1 0 0 U
B. HOW DID LAST MARRIAGE END? (3) c1DIVORCE (3) 0 ANNULMENT (2) 0 DEAlH B. HOW DID LAST MARRIAGE END? (3) cf DIVORCE (3) 0 ANNULMENT l2l.D DEAlH
C. DATELASTMARRlAGEENDEO? 11/ 22 / 2004 C. DATE LAST MARRIAGE ENDED? 07 / 12 /19W
MONTH DAY YEAR MONTH-"", DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? C:r4ES 0 NO D. ARE ANY FORMER SPOUSE(S) AUVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (ClTYICOUNTY. STATE/COUN11'lY. IF NOT USA) SELF SPOUSE (MONTH. DAY. YEAR) (CrTYtcOUNTY. STATEICOUN11'lY.IF NOT USA) SELF SPOUSE
11/22/2004 poughkeepsie. New York cf 0 1ST 07/1211999 Dutchess Co., New York 0 d
o 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
my knowledge and belief that the information I provided is diment exists
D~
1ST
2ND
3RD
4TH
I duly swear/affirm, dep'05e and say, that to the best
as to my right to enter into the m state.
21. SIGNATURE OF GROOM~
23. SU8SCRIBED AND SWORN T~
SIGNATURE OF TOWN OR C CL ~ ,.
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations 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 only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
USE CURRENT NAME
DATE 0511012006
by New York Domestic
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
MAILING ADORES
'-v-' .
09 2006
TIME
MONTH
YEAR
MONTH
YEAR
AM
06:33PM
05
11
2006
07
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE Oroy;rHE
DATE AND AT THE TIME AND
1 s: CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYJJJ7C/~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF Jf VILLAGE OF
SPECIFY ~PtN~' fiJ~
SIGNATURE
DOH-98 10712005\
NAME (PRINT)
SIGNATURE~