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L A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
F'IWC Jo,epb R~&,biaro
1
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY nlltr.he~~
CITYITOWN Wappinger
~~J~kc; 1 ~fiR
~5~I~J~R 14R
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
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11. A. FULL NAME lfitllNl Angelir.a Amendnla
CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
B BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Ruggiero
c. s~~~(M'Z~~~t~~e~~SE) c. s~~~~~~~t~me~~sP'i ~!'~~7r7n
D. SOCIAL SECURITY NUMBER 13~3S-7912 D. SOCIAL SECURITY NUMBER nna-~:'1
2. RESIDENCE A. N~TXodc: B. ~SS 12. RESIDENCE A.N'1fA-Xrrlr B. ~~~~
C. CHECK ONE 0 CITY ~ TOWN 0 VILlAGE C. CHECK ONE 0 CITY rg TOWN 0 VILLAGE
AND I.... ANDW'
SPECIFY fit L.n-ngp. . SPECIFY applnger
D. STREET ADDRESS 281 Walsh Road ZIP 12540 D. STREET ADDRESS51 Brown 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? ~ YES ~ NO
3. A. AGE 55 3B. DATE OF BIRTH Mm / ~ / ti~O 13. A. AGE 44 13.B. DATE OF BIRTH ~NTH .toDAY ~1AR--
4. EMPLOYMENT 14. EMPLOYMENT
A. USUAL OCCUPATION Ele~rir-al r.:nntrAclnr A. USUAL OCCUPATION HOIJ~Mlrife
B. TYPE OF INDUSTRY OR BUSINESSSelf-p.mpl~d B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH ~~~~~~I~~) 15. PLACE OF BIRTH ~~~CO~R~P~ USA)
6. FATHER 16. FATHER
A. NAME Jo~eph Anthnny ni r.:hiRm A. NAME Anthony U Rlqagiem
B. COUNTRY OF BIRTH l J S A B. COUNTRY OF BIRTHU S A
7. MOTHER 17. MOTHER
A. MAIDEN NAME Catbedne Vitale A. MAIDEN NAME Ro,e A ~$If1d,,1fi
B. COUNTRY OF BIRTH l J S A B. COUNTRY OF BIRTHU S A
8. NUMBER OF THIS MARRIAGE 3 18. NUMBEROF THISMARfUAGE ..~
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT DEATH
2 0 0 1 0 0
B. HOW DID LAST MARRIAGE END? (3) r!!! DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) r:! DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 03 / 10 /2003 C. DATE LAST MARRIAGE ENDED? 12 / 05 /1991
MONTH DAY YEAR MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? [!rYES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION"
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STAWCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STAWCOUNTRY. IF NOT USA) SELF SPOUSE
'111211QR7Whit.,,pt.... New Vnrlr r!!! 0 1ST 17/f1!;/1QQ7 White PIRinR, New York ~
Q3110f7111" "P(j............gjp. . "New VtVIr ~ 0 2ND 0
~,
o 0 3RD 0
o 0 4TH
e best of my knowledge an be ief that the information I provide
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2ND
3RD
4TH
I, being duly SWDm, depose and say, that to
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM ~ a.....
23. SUBSCRIBED AND SWORN TO BEFORE ME 1113ft1"'l005
SIGNATURE OF TOWN OR CITY CLERK~ DATE - --~---
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
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 CLE~ 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
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{ SEAL }
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YEAR
MONTH
YEAR
TIME
MONTH
AM
04:33 PM 12
01
2005
01
29 2006.
IP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. couN~1df.€Sl.
)
STREET C
~~~R~~Ri~~~ 10~0~~N~i~ 26. SOLEMNIZATION OCCURRED
SONS NAMED ABOVE ON THE TIME MO. AY i YEAR
DATE AND AT THE TIME AND '7J'o. _ f
PLACE INDICATED. I ~ PM 1-- /,z, oS 9 0 OTHER, SPECIFY
~ ~
~~;m; wpGfJ1 r;:J~~' ,~~<:r~"":J.'1I
SIGNATURE~ 1!~~ DATE ,2>$0..;<" I :Z&>oS
MA"}rtjfWiyt)f~ .11. uJl1f::fJrrN~ r~ N,ft'lf.)..~tf()
STREET CITYITOWN STATE
30. WITNESS TO CEREMONY
~-.
1~ CIVIL
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF jJf., TOWN OF 0 VILLAGE OF
SPECIFY ~ r .li.J!{f( fGt./"
....-.....,-,..~,
NAME (PRINT)
SIGNATURE ~
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