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1. A. FULL NAME
~ I A II:. UI- NI:.W YUHK.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~amuel Alevander ~n~ntino
FIRST MIDDLE CURRENT SURNAME
CURRENT SURNAME
(THIS SPACE FOR STATE USE ONL Y)
COUNTvf). dr-he!;!;
CITYITOWNWappinger
~~~~~c:136R
~5~'~J~~
L 0 SUPPLEMENTAL FILE
--.J
11. A.
FROM THE BRIDE
FULL NAMEJenM,r Anne S~~
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE C:::or.rentino
(OPTIONAL. SEE REVER~)
D. SOC IAL SECURITY NUMBER 13 ~ 72 3703
12 RESIDENCE iN~TXert B~S
C. CHECK ONE 0 CITY.tJ TOWN 0 VILLAGE
AND
SPEclF'8eel(man
D. STREET ADORES~ 27 '3 Greenhaven Road zI112582
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEM] NO
13. A. AG~1 13.B. DATE OF BIRTH otONTH oJ DAY 1~EAR
14. EMPLOYMENT
A. USUAL OCCUPATIOllllnemployed
8. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTf5~n:f&~ml
16. FATHER
A. NAMiRonald Sisco
8. COUNTRY OF BIR1\!J S A
17. MOTHER
A. MAIDEN NAMECassandra \.'an Dyne
B. COUNTRY OF BIRT\JJ S A
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
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B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE~
D. SOCIAL SECURITY NUMBER 1'~ 7'-1716
2. RESIDENCE A.New Ynrk B. ~ss
C. CHECK ONE (STAgl CITY"I'J TOWN 0 VILLAGE
ANDp hk .
SPECIFY QUa eepsle
D STREETADDREss12 Meyer Avenue ZIP 176n3
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YE9'tJ NO
3. A. AGE28 38. DATE OF BIRTH ~tH -1~AY ~ ill
4. EMPLOYMENT
A. USUAL OCCUPATION Heavy Equip Mer.hanir.
8. TYPE OF INDUSTRY OR BUSINESsP-ine RII!i:h Fq.'ip
5. PLACE OF BIRTtP-?c~~n~T~rce~L~ IF ~~IV nrlr
6. FATHER
A NAME Vincent Sorrentino
B. COUNTRY OF BIRnt J ~ A
7. MOTHER
A MAIDEN NAME Cathenne Dora Moms
8. COUNTRY OF BIRTH I J S A
B. NUMBER OF THIS MARRIAGE'
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 n n
8. HOW DID LAST MARRIAGE END? (3'!'D DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? n6 /,Q /'01)4
MONJ.li 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
lSTn6090m14 Mar~hall Co ,Aletlftme ~ 0
mD 0
3RD 0
4TH
I, being duly sworn, depose and say, t
as tD my right to enter intD the marria
21. SIGNATURE OF GROOM ~
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(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
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
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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 State of e 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.
o 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
DATE 08/1 on005
by New York Domestic
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
~ '&I~tddiE
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
MONTH
YEAR
TIME
MONTH
AM
PM 8
11
2005
o
09 2005
6:34
ZIP
2B. PLACE WHERE MARRIAGE OCCURRED
fA fd<.e.M
10 CIVIL
A. STATE NEW YORK 8. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 5lI TOWN OF 0 VILLAGE OF
SPECIFY !VUJhltufSl ~
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
DOH-BB (11/BB)
..NAME (PRINT)
SIGNATURE ~