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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
stQi\eft Mietu.IlLraliehetli. JR~NT SURNAME
I
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
COUNTY Dutohess
CITYiTOWN \AfepplAger
DISTRICT ..
~~~I~~~R1368
NUMBER 129
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME Jo "" Mafie RiDlf'O
CURRENT SURNAME
Q.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ,",.-I'.eh'.-M:
(OPTIONAL - SEE REVER!EjQl IVUI
D. SOCIAL SECURITY NUMBER 098-62 8G34
12. RESIDENCE ANewX~Fk B. Ol4&dullil!
C. X~5CK ONE 0 CITY ~ TOWN 0 VILLAGE
SPECIFY~JappAI8I'
D. STREET ADDRESl61 Fieldstone BouIevarcl
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
B. BIRTH NAME, IF DIFFERENT'
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SDCIAL SECURITY NUMBER 11s.68-6310
2. RESIDENCE A. N_~aFk B. ~
C. X~6CK ONE 0 CITY ~ TOWN 0 VILLAGE
SPECIFY FlShkill
D. STREET ADDRESS 34 Croe_ CouFt
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILL!AGE?
3. A. AGE3G 38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION TFUdc DIN..
B. 1YPE OF INDUSTRY OR BUSINESS Jez J Mar Carting
5. PLACEOFBIRTH~J\~X_USA)
6. FATHER
13.B. DATE OF BIRTH
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13. A. AGE31
14. EMPLOYMENT
A. USUAL OCCUPATIONTdle ClClIB..
B. TYPE OF INDUSTRY OR BUSINESS Self &mplQV8d
15. PLACE OF BIRTH~~ ~sY,orIc
16. FATHER
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A. NAME stephen Mi.. PaliGhelti. Sr.
8. COUNTRY OF BIRTH USA
7. MOTHER
A. NAME[)gminiclc.~ RiganCJ
B. COUNTRY OF BIRTIU S A
17. MOTHER
A. MAIDEN NAME Marilyn Ann CeleNe
B. COUNTRY OF BIRT~ S ^
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A. MAIDEN NAME Mary L.ouI5e ChlonchIo
B. COUNTRY OF BIRTH U S ^
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
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) (CIT\', STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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
o
o
o
o
o
o
o
o
o
. SIGNATURE OF BRI
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DA E
This license authorizes the marriage in New York St of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is t be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK . , 25. A. SOLEMNIZATION PERIOD BEGINS
{ SEAL } ;;~~ om 1ew&rJ0D5 "ME m "" ....."
'-v-' ~ Middlebusb Rei. Wappi~f8l1s. N'(TA~90 ZIP :01 ~~ 10 07 2005 12 05 2005
~~~R~~~Ri~~~ 10~Oi~~N~~E~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 K RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. o.s- 9 0 OTHER, SPECIFY
York Domestic
YEAR
2B. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTyUtri1l.oLL
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY &. At 7+r~ t; D ,
NAME (PRINT)
SIGNATURE ~
DOH-9B (11/9B)
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) ko...u n e
SIGNATURE~ c:1~
A. ~ob\OJl(O
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