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1. A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
. CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Dominick Raymond Chiero, Jr.
FIRST MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutchess
CITY/TOW~ Wappinger
DISTRICT "136l::1
NUMBER
~G~'~J~R '2Q
L 0 SUPPLEMENTAL FILE
11. A.
FROM THE BRIDE
FULL NAME Marianna Naldi
FIRST MIDDLE
CURRENT SURNAME
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B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Chiero
(OPTIONAL. SEE REVERSE) 118-60-8211
D. SOCIAL SECURITY NUMBER
12 RESIOENCEANew York B Dutchess
(STATE) '" (COUNTY)
C. CHECK Ot-l.i, 0 CITY D TOWN D VILLAGE
~~~CIFY wappinger
19 I horn Acres Drive
o. STREET ADDRESS
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE38 13.B. DATE OF BIRTH 02 )3
C. SURNAME AFTER MARRIAGE
D. Sci~~:'~~tuLR~T~E~U~~~~RSE061-68-9648
2 RESIDENCE A. New York B. Dutchess
(STATE) 0#* (COUNTY)
C. CHECK ONf_, 0 CITY D TOWN D VILLAGE
~~~CIFY wappinger
D. STREET ADDRESS 19 Thorn Acres Dnve
ZIP 1259u
.,
DYESDNO
1.968
YEAR
u590
ZIP
....
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES D NO
3. A. AGE 38 38. DATE OF BIRTH 10 /08 /1967
MONTH DAY YEAR
MONTH
DAY
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4. EMPLOYMENT
A. USUAL OCCUPATION Tree Climber
B. TYPE OF INDLl."IflY.~ BUSIN~sp yorktown Lanascape
5. PLACE OF BIRTHMl. I\ISCO, New York
(CITY. STATElCOUNTRY IF NOT USA)
6. FATHER
A. NAME Dominic Raymond Chiero, Sr.
B. COUNTRY OF BIRTH U ~ A
7. MOTHER
A. MAIDEN NAME Lucrezia Servello
8. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE l.
14. EMPLOYMENT
A. USUAL OCCUPATION Administrative Assistant
15 :~::~~:I;~~roo~~:W~~~::up
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Ronald Naldi
8. COUNTRY OF BIRTHU ~ A
17. MOTHER
A. MAIDEN NAME Crescenza D' Donato
8. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIOORCE CIVIL A~ULMENT
Dlj TH
DljTH
YEAR
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YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TYPE OF CEREMONY
o !ltRELlGIOUS
9 D OTHER, SPECIFY
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF D TOWN OF D VILLAGE OF
SPECIFY S T A i E AI .I Sol1\. h j
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
)0"'1S
TITLE
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~19106
NAME (PRINT)
SIGNATURE ~