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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FBOM THE GROOM
David F. Di Dio
I"
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
Dutchess
COUNTY v.pp
CITYrrO~ IVl'I
DISTRICT 368
NUMBER 1 7
REGISTER 1
NUMBER .
11. A.
L 0 SUPPLEMENTAL FILE
Na FJ:~J;~RIDE
FULL NAME ncy
FIRST MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
a.
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), tjFfjlC)'T
C. S~~~~~M~~~~:~~e~~SE) 11~3407
D. SOCIAL SE~'. Dl4chess
12. RESIDENCE A. (STATE)'; B. (COUNTY)
C. CHECK,*,i.,--Jil..~ 0 TOWN 0 VILLAGE
AND VVIIpplllygI
SPECIFY 7C Alpine Drtve 12590
D. STREET ADDRESS ZIP .,
E. IS RE~CE WITHIN LIMITS OF CITY OR INCORPORAff3"LLAGE?'V\ 0 :taiJr. NO
13. A. AGE 13.B. DATE OF BIRTH L ~
MONTH DAY YEAR
14. EMPLOYMENT AI R Specillist
A. USUAL OCCUPATION
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)124-66-0456
D. SOCIAL SE~~ER vvesrcnester
2. RESIDENCE A. ark B.
(ST...,) (COUNTY)
C. CHECK ONh_ -.O..-"r 0 TOWN 0 VILLAGE
AND t"'eDK5KIl
SPECIFY 7" U -A.
~ nggyef ",venue
D. STREET ADDRESS Z~
E. IS REVCE WITHIN LIMITS OF CITY OR INCORPORATED~GE? A"fJ
3. A. AGE 3B. DATE OF BIRTH ~
MONTH DAY
4. EMPLOYMENT
10588
YES~
/1~1
YEAR
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Carpenter
A. USUAL OCCUPATION M~ Qaft
B. TYPE OF INDUesa~ ~ '(grit
5. PLACE OF BIRTH
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER Frank John Di Dia
A. NAME USA
B. COUNTRY OF BIRTH
B. TYPE OF IND~ ClICiiaencl. t .low ..torte
15. PLACE OF BIRTH
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER Anthony Piamonle
A. NAME USA
B. COUNTRY OF BIRTH
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7. MOTHER
17. MOTHER cermelll VI~nll Plccllno
A. MAIDEN NAME U 6 A.
B. COUNTRY OF BIRTH 1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DllfRCE CIVIL A~LMENT
D~H
GlorIllrene WeIse
A. MAIDEN NAME USA.
B. COUNTRY OF BIRTH 1
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~CE CIVIL ANlfLMENT
DEffH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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
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o
o
1ST
2ND
3RD
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. SIGNATURE OF BRIDE ~
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York Stat of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within W York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN O~CI~Mastelrson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) _~----::.-
S. :1912005 TIME MONTH DAY YEAR MONTH
EAL SI~...IJ.FlIi JlA..TF
MAJ!\'IWH nger NT 12:)90 11
'-v-' '
STREET CITYrrOWN STATE
1 CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27~TYPE F CEREMONY
THE MARRIAGE OF THE PER- .
SONS NAMED ABOVE ON THE .IME MO. DAY YEAR 0 ELIGIOUS 10 CIVIL
DATE AND AT THE TIME AND 'i
PLACE INDICATED. 9 0 OTHER, SPECIFY
ZIP
29. OFFICIANT
NAME (PRINT)
;e. C. lk'Esr
10 k/tJs-"
, . /Ol59o
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~;Tti/~
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~GE OF
SPECIFY Jf/AftO'N6ti"A2S PriuS
TITLE
STREET CITYrrOWN
:::::~~ 'r. /'1 A ~ A .AI ()
SIGNATURE~21L-~~ ~
DOH-98 (11198)