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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
Brya~~T~~~OM
Dutchess
COUNTY \MIPJi
Gl"'4VtTOYft nger
DISTRICT 368
NUMBER 112
REGISTER
NUMBER
1. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
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N
B. BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE09S-72-4052
0, SOCIAL SE~~ER
2, RESIDENCE A, one B, lJLItCI1eSS
(STATE)" (COUNTY)
C, ~~6CK OOWaPiirfairO TOWN 0 VILLAGE
SPECIFY 14 Kcm<WI[)rh,o
0, STREET ADDRESS ZIP
E. IS RE~CE WITHIN LIMITS OF CITY OR INCORPORATEDCirGE? ~
3, A, AGE 3B, DATE OF BIRTH /-
MONTH DAY
4, EMPLOYMENT
12590
.,
Y/1915
YEAR
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A, USUAL OCCUPATION \J ~4~ "- '-
V... ar mV\l. YVI_1V1
B, TYPE OF INDIJPi!\Y.~ "---' . k
5, PLACEOFBIRTH~I~e.l~ ,ur
(CITY, STATE/COUNTRY IF NOT USA)
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6, FATHER Edward Hubbard
A, NAME USA
B, COUNTRY OF BIRTH
7_ MOTHER aafe Kedzlel8WI
A, MAIDEN NAME U 6 A
8. COUNTRY OF BIRTH 1
8, NUMBER OF THIS MARRIAGE
9, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1V<OCE CIVIL A'lfLMENT
DE(1H
B, HOW DID LAST MARRIAGE END? (3) [] 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
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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
Di FROM TI::II E BRIDE
anne CIccarellO
11. A, FULL NAME
CURRENT SURNAME
FIRST
MIDDLE
e, BIRTH NAME (MAIDEN NAME), ~6fIh:j
C, SURNAME AFTER MARRIAGE ~7~
(OPTIONAL - SEE REVERSEJUgOI" ""'OJOTJ
0, SOCIAL S~'8Ik Dutc1aess
12, RESIDENCE A, (STATE) rI B, (COUNTY)
C, ~6CK 'VVa~ 0 TOWN 0 VILLAGE
SPECIFY 14 Kendell Drtve 12590
0, STREET ADDRESS ZIP .;
E, IS RE~CE WITHIN LIMITS OF CITY OR INCORPORAIWiIlLLAGE~ [] 1~ NO
13, A, AGE 13,B, DATE OF BIRTH --
MONTH DAY YEAR
14, EMPLOYMENT Financial Service Rep.
A, USUAL OCCUPATION H. V. F. C. U.
B, TYPE OF IND~e. NM'Vork
15, PLACE OF BIRTH
(CITY, STATE/COUNTRY IF NOT USA)
16, FATHER Anthony Charles Ciccarello
A, NAME USA
B, COUNTRY OF BIRTH
17, MOTHER Marilyn ~Ione
A, MAIDEN NAME U (; A
8. COUNTRY OF BIRTH 1
18, NUMBER OF THIS MARRIAGE
19, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIO'RCE CIVIL A1JULMENT
D'!)TH
B, HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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o 0 4TH
nowledge and belief that the information I providfil;
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21. SIGNATURE OF GROOM ~
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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
Relations Law !i11 to perform marriage ceremonies within
o If checked, this license is to
24, TOWN OR CIBt
NAME (PRINT)
DATE
of the bride and groom named above by any person authorized by New
W York State. THIS LICENSE VALID IN NEW YORK STATE ONLY,
e used only for the purpose of a second or subsequent ceremony.
25, A, SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-..,-I
York Domestic
25, S, SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
11
07 2005
YEAR MONTH DAY
YEAR
. ~ 12:)90
ZIP
02:42 AM 09
PM
STATE
27, TYPE OF CEREMONY
0')( RELIGIOUS
9 0 OTHER, SPECIFY
(<. C. pR.l'eST
CX-r: /6,2otJS
13.S'
HCP6We.,,- .J'CT
STATE
10 CIVIL
28, PLACE WHERE MARRIAGE OCCURRED
A, STATE NEW YORK B, COUNTY:V~SS'
C, LOCATION OF CEREMONY
(CH<ECK ONE AND SPECIFY)
o C~TY OF ~ TOWN OF
'B
SPECIFY
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[] VILLAGE OF
'F"t W k. fL.L-
ZIP
" .",,'" on C'""""" ~
NAME(PRINT)~
SIGNATURE ~