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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
Vi~~~~a, JR.
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
knowledge and belief that tht;l information I provided is true and that I declare that no, ler~ impediment exists
. SIGNATURE OF BRIDE ~ -M--/...~ ~/ ~./
USE CURRENT NAME 09ID2I2005
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 911 to perform marriage ceremonies within N w 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.
{ ~ } ~:~~~:I~~"B t. Mill-=-- 25. A. SOLEMNIZATION PERIOD BEGINS
SEAL SIGNATURE" _ C- ~ Pa.Tj: D9I02faJ:) TIME Q9MONTH YEAR M101NTH
MA!MtII R ppngerFalls, NY 1~ 01:49~M
'-v-I STREET CITY/TOWN STATE ZIP M
I CERTIFY THAT I SOLEMNIZEO 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
~~SM~~~~~~B~vJH~N Pi.fE TIME MO. DAY YEAR 0 M. RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
COUNTY ~!SS
CITYfTOWf pPnger
DISTRICT 368
NUMBER
REGISTER 104
NUMBER
1. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
ll.
N
B. BIRTH NAME, IF DIFFERENT
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C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEI050-7D-2529
2. ~~S::~~~ :EC~U'anc B. DUtCI1eSS
(STATE) "'TV ~ (COUNTY)
C. ~5CK ONEastif:"1Ih1dlf TOWN 0 VILLAGE
SPECIFY !&4 TDwIWIew DrIve
D. STREET ADDRESS ZIP
E. IS RE~CE WITHIN LIMITS OF CITY OR INCORPORATED~GE? ~
3. A. AGE 3B. DATE OF BIRTH /
MONTH DAY
4. EMPLOYMENT DIstrIct Manager
A. USUAL OCCUPATION Eutb. h,., Rtmt A Car
B. TYPE OF INDUflbiR ""utk t.lII
5. PLACE OF BIRTH '
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER Vincent Anthony La Bell
A. NAME 8
8. COUNTRY OF BIRTH U 6 A
12510
'II
Y~8919
YEAR
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7. MOTHER M An"-"-'" Sanglacom
A. MAIDEN NAME Iry n IIRI'Iv;MI 0
B. COUNTRY OF BIRTH U 6, A
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1V~CE CIVIL ANtfLMENT
DE(fH
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
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
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29. OFFICIANT
NAME (PRINT)
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L D SUPPLEMENTAL FILE
MeI~~~ ~E BRIDE
~
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), [iF.I.
c SURNAME AFTER MARRIAGE ~
. (OPTIONAL - SEE REVERSEl085-72-.;KKIU
D. SOCIAL SE~'~ Dutchess
12. RESIDENCE A. (STATE)"; B. (COUNTY)
C. ~5CK ~est PlsfilOlP TOWN 0 VILLAGE
fI SPECIFY 384 Towr~_ Drtve 12596
D. STREET ADDRESS ZIP .;
E. IS RE~~CE WITHIN LIMITS OF CITY OR INCORPORAllflLLAGE??I\ 0 ~.M NO
13. A. AGE 13.B. DATE OF BIRTH ~ ~
MONTH DAY YEAR
14. EMPLOYMENT
HaIrdresSer
A. USUAL OCCUPATION FI'IWc cut.
B. TYPE OF INDLlBIB'LJJf.LElUS1N1\I,w L . k.
MIDnlImGr. T UI
15. PLACE OF BIRTH '
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER Jaseph Francis ViIi
A. NAME USA
B. COUNTRY OF BIRTH
17. MOTHER
Ann Mlrle BonfIrdecI
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH 1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIO'RCE CIVIL A'lfLMENT
DI'()TH
B. HOW 010 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
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY I1fJ<.Ki f.1fl
o
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF Ii.. VILLAGE OF
SPECIFY r::-r A rJ K fo f( r: Al J t
NAME (PRINT)
SIGNATURE ~