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1. A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
J~Wh Angel~lI~~iRO
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY nlltr.hf!~~
CITYffOWN Wappingf!r
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A.
FULL NAME K~ne JuliaQjIilo~IQck3hca[URRENT SURNAME
CURRENT SURNAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Dlaekshcar
(OPTIONAL - SEE REVERS~
D. SOCIAL SECURITY NUMBER 088 7Q.-3031
12. RESIDENCE A.Virg_ B (COUNTY)
C. CHECK ONE ~ CITY D TOWN D VILLAGE
AND
SPECIFY Newport News
D. STREET ADDREss5D5 Dartmoor Drive ZIP236DS
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? oi'J YES D NO
OfJJNTH 20 DAY 197iAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 098 62 5647
2. RESIDENCE A. Vi~~a B (COUNTY)
C. CHECK ONE ~ CITY D TOWN D VILLAGE
AND
SPECIFY Nf!lAlpQrt News
D. STREET ADDRESS 505 Dartmonr nrivf! ZIP 2360R
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? -tJ YES D NO
3. A. AGE"g 38. DATE OF BIRTH 1..1 /,,>1. / 1..0.2~
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13. A. AGE26
14. EMPLOYMENT
13.B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Natural Re~ource Spec.
B. TYPE OF INDUSTRY OR BUSINESS Statf! Of Virgif'lla
5. PLACE OF BIRTH"'~~ st!~~m.~l~J;~Ar nrtr
6. FATHER
A. NAME Anth()ny D Cimino
8. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A. MAIDEN NAME Marilyn R. Grasso
8. COUNTRY OF BIRTH I I 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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(3) D ANNULMENT
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(2) D DEATH
A. USUAL OCCUPATION Lab Research Specialist
B. TYPE OF INDUSTRY OR BUSINESS College Of Wm. & Mary
15. PLACE OF BIRTH~~~EM~OOPlY'~mMota
16. FATHER
A. NAMEEdmund Da~Jid Blackshear
B. COUNTRY OF BIRTtU S A
17. MOTHER
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A. MAIDEN NAME Susan Elizabeth Adam3
B. COUNTRY OF BIRTtU S .to.
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
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(2) D DEATH
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B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
(3) D ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
D D
D D
D D
D D
o gal ir~ediment exists
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D D 1ST
D D 2ND
D D 3RD
D D 4TH
my knowledge and belief that the information I provided is true a~.).l:lat I peclare t
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21.
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Stat 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.
D 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
by New York Domestic
~
{ SEAL }
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NAME (PRINT)
TIME
MONTH
DAY
YEAR
MONTH
YEAR
22
2005
01 20 2006
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTyD~e.4
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF )t TOWN OF D VILLAGE OF
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