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1. A. FUll NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael David Molinelli
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutchess
CITYfTOWl'! wappinger
DISTRICT 1368
NUMB~R
REGISTER 69
NUMBER
MIDDLE
CURRENT SURNAME
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME Stephanie Robin Masiello
FIRST MIDDLE
CURRENT SURNAME
11. A.
FIRST
B. BIRTH NAME (MAIDEN NAME). UO?RENT
C. SURNAME AFTER MARRIAGE anelli
(OPTIONAL - SEE REVERSElQ5'7 -74-3753
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A.New Jersey B. Ocean
(STATE)'; (COUNTY)
C. ~6CK 0r:0I'Iteii tiY 0 TOWN 0 VILLAGE
SPECIFY er
D. STREET ADDRESS 458 l::S8I1l8C1e I<oed
ZIP 08131
o YES~ NO
1JW6
DAY YEAR
B. BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEl139-84-7390
o SOCIAL SEC~~.U~~~-==
2. RESIDENCE A.IeIl!M'Y B. Ocean
(STATE)'; (COUNTY)
C. ~~6CK ONi=orkiI 'iiv TI TOWN 0 VILLAGE
SPECIFY er
o STREET ADDRESS 458 Bamec1e I<oed
OB7al~4
ZIP
YES ~ NO
/19n
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE28 13.B. DATE OF BIRTH 12 Q2
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0
3. A. AGE Zl 3B. DATE OF BIRTH 10 /05
MONTH DAY
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Employee CommuricalionS Mar.
B. TYPE OF IND~T_R2'~B~I;;:esonsA1l8l1llC CIlY
15. PLACE OF BIRTHl:5IUOIQYn, York
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Thomas Mllliello
B. COUNTRY OF BIRrJJ 5 A
17. MOTHER ...
A. MAIDEN NAME Gretchen WIIlace
B. COUNTRY OF BIRTJJ S ~
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI60RCE CIVIL A'6UlMENT
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4. EMPLOYMENT
A. USUAL OCCUPATION Engineer
B. TYPE OF INDU~OIrqR~SINESS 5cnoor De P81ma
5. PLACE OF BIRTH III Heese"" NeW JeI5eY
(CITY, STATE/COUNTRY IF NOT USA)
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6. FATHER
A. NAME John DavId MallneDi
B. COUNTRY OF BIRTH U 5 A
7. MOTHER
A. MAIDEN NAME Ann Marie Paulettl
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1VccrCE CIVIL A~ULMENT
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
D~TH
DlSTH
B. HOWDID 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
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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1ST 0 0 1ST
~ 0 0 ~
~ 0 0 ~
4TH 0 0 4TH
I, being duly swom, depose and say. that to the best of my knowledge and belief that the information I provided i
as to my right to enter into the marr" e !iltat .
21. SIGNATURE OF GROOM ~
. SIGNATURE OF BRIDE
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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 St
Relations Law ~11 to perform marriage ceremonies withi ew 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 C~fiRC MasteIson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) 2.
SEAL ,~~ rrTl'Z2I2rJJ5 TIME MONTH DAY YEAR
SIGNATURE ~ _ ~_ _ DATE
M2a<Mm R .nger Falls, NY 12590
~ STREET CITYITDWN STATE
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27~TYP OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 RELIGIOUS 1 0 CIVIL
~tr~E ~~glITJ~E TIME AND t1>O AM 9 0 OTHER, SPECIFY
09
20 2005
by New York Domestic
YEAR
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~N OF 0 VilLAGE OF
SPECIFv!3(('rHJ?/Ilie, C~
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE