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1. A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jo~~ ,Alejandro ~PjjR
I S MIDDL
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STAll:. ~ILt; NUMD~n
(THIS SPACE FOR STATE USE ONL Y)
COUNroutcl'les~
CITY rrowrWappingp.r
~~~~kcR136a
REGISTE'30
NUMBER
CURRENT SURNAME
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME Maddalena Maria Petrillo
FIRST MIDDLE
CURRENT SURNAME
11. A.
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Meiia
(OPTIONAL - SEE REVERSEA55-64-6761
D. SDCIAL SECURITY NUMBER U
12 RESIDENCE ..New York BDutchess
(STATE) oJ.. (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFYWappinqer
D. STREET ADDREss179 Osborne HIli Road
ZIP' Z~Z4
.,
o YES 0 NO
1917
YEAR
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER
2. RESIDENCE A Ne!fA~pr.k
C CHECK ONE 0 CITY'll] TOWN
AND W .
SPECIFY applnger
D STREET ADDREss17Q O~bome Hill Road ZIP 12524
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"tJ NO
3. A. AGE26 3B. DATE OF BIRTH----r;Q~H /2~y /1~lR9
4. EMPLOYMENT
B.. D'(OO~~~
o VILLAGE
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGI=?Q 13.B. DATE OF BIRTH 03 j-6
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATIONColleae Student
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRT~ronx. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMESalvatore Petrillo
B. COUNTRY OF BIRT~ta\Y
17. MOTHER
A. MAIDEN NAME Angela Fischetti
B. COUNTRY OF BIRTrU S A
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
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A. USUAL OCCUPATION Shod Line r.:nnk
8. TYPE OF INDUSTRY OR BUSINESS nlJtr.he~s Diner
5 PLACE OF BIRTHZ~~ffi~~~olJ~'$~~~u~P.XiCO
6. FATHER
A. NAME Emiliano Mejia
8. COUNTRY OF BIRTH fu'p'yjr.n
7. MOTHER
A MAIDEN NAME Elvira Elena Vela~co
B. COUNTRY OF BIRTH Me>lic()
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. HOW DID 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
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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DEATH
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B. HOW DID 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 ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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1ST
2ND
3RD
4TH
I, being duly sworn, depDse and
as tD my right to enter into the m
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21. SIGNATURE OF GROOM
04/18/2006
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23. SUBSCRIBED AND SWORN TO BEFORE
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State 0 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
DATE
by New York Domestic
~
{ SEAL }
'-.,-l
YEAR
YEAR
MONTH
TIME
MONTH
NAME (PRINT)
DATE 04/18/2006
Y 12590
STATE
27. TYPE OF CEREMONY
AM
ZIP 01 :29 PM 04
1~':L
19
2006
06
17 2006
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8 COUN~l,(TG~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF ~ILLAGE OF
SPECIFY /IJ~~ ~
SIGNATURE~ ~
DOH-96 (11/96)
SIGNATURE ~