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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
R~and Ch"=~ R~~RENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutchess
CITYrrOWN ~pplnger
~~J:kCRT 1368
REGISTER 74
NUMBER ,
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Gifl\,Marie Ci~LE
CURRENT SURNAME
11. A. FUUL NAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~N~~~~t~~e~~S~enzo
D. SDCIAL SECURITY NUMBER 121-.64-9183
12. RESIDENCE A. t-J.~ork B. ~~~BS
C. CHECK ONE 0 CITY [ijIl TOWN 0 VILLAGE
AND Wa .
SPECIFY. ppnger
D. STREET ADDRESS 1668 Route 9 I tnIt 2 B ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 25 13.B. DATE OF BIRTH 1ArrH 17 DAY 197~AR
14. EMPLOYMENT
A. USUAL OCCUPATION TeIICher
B. TYPE OF INDUSTRY OR BUSINESS ~JM.Jburgh Sch. Dist.
15. PLACE OF BIRTH~jJ.'Yort
16. FATHER
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1- ~ ~
D. SOCIAL SECURITY NUMBER -~~
2. RESIDENCE A. ~ VtVlr B. n..t'""'-.
'-'(m'TE) ~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND lA.I- .
SPECIFY V1Rllppnger
D. STREET ADDRESS 1688 Route 9 Unit. 2 B ZIP 1~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 29 3B. DATE OF BIRTH M~ /1&16
4. EMPLOYMENT
A. USUAL OCCUPATION stAte TR'Jl1f'P-I"
B. TYPE OF INDUSTRY OR BUSINESS N V S PftIIM
5. PLACE OF BIRTH ~m~l~n)
6. FATHER
A. NAME RlQfIDand WII18m Ren70
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Sber.. Beine Van Tassel
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
(3) 0 ANNULMENT
/ /
A. NAME Micb8el Ciulla
B. COUNTRY OF BIRTHItaIy
17, MOTHER
A. MAIDEN NAME I..uc:Ille ~no
B. COUNTRY OF BIRTHU SA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
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DEATH
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(2) 0 DEATH
DEATH
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B. HOW DID LAST MARRIAGE END? (3) DOIVORCE (3) 0 ANNULMENT (2) 0 OEATH
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
B. HOW.DID LASH4ARRIAGEEND? ..(3)D ~IVORCE
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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1ST 0 0 1ST
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I, being duly sworn, depose and say, that to the best of my knowledge and be lef that the information I provide
as to my right to enter into the arria e
21. SIGNATURE OF GROOM ~ . SIGNATURE OF BRIDE ~
o 0
o 0
o 0
o 0
ediment exists
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23. ~::~..fT~~~Do~N.fo~06'~ 6~Bg~~~~E DATE 07n7~
This license authorizes the marriage in New York Stat 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 be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
MMUf&JS
'-,,-I 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
YEAR
MONTH
TIME
MONTH
DATECJ7Q7DlV.'t5
11:14 AM 07
PM
28
2005
09
25 2005
ZIP
SATE
27, TYPE OF CEREMONY
o)ti RELIGIOUS
9 0 OTHER, SPECIFY
CI /TOWN
26. SOLEMNIZATION OCCURRED
TIME M DAY YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY pu\c.hQ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
7CITY OF iJ ,u,~F 0 VILLAGE OF
SPECIFY Sect C~
10 CIVIL
NAME (PRINT)
SIGNATURE~
DOH-9a (11/98)
SIGNATU
