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COUNTY
CITYITOWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rohert John Alltorino
FIRST MIDDLE
I
STATE ALE NUMBER
(THIS SPACE FOR STATE USE ONLY)
Dutr""~gg
\Alsppingp-r
1368
58
L
o SUPPLEMENTAL FILE
FROM THE BRIDE
Linda Ann Di Chiaro
FIRST MIDDLE
1. A. FULL NAME
11. A. FULL NAME
CURRENT SURNAME
CURRENT SURNAME
...
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1""8 6n3486
D. SOCIAL SECURITY NUMBER _ ~- - _!J::___
2. RESIDENCE A. NV . B. nlltchess
(~) (CO~
C. CHECK ONE 0 CITY 0 ~N 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 1? Alden Court
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
nv
MONTH
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Autorino
(OPTIONAL - SEE REVERSE) 114-64-3304
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B Dutchess
(STATE) J . (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~CIFY Fishkill
D. STREET ADDRESS 13 Alden Court
1;l~;l4
"
YES 0 NO
/1964
YEAR
3. A. AGE
41
ZIP 12524
OYESori>
1Q/ 19
DAY YEAR
14. EMPLOYMENT
ZIP
E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
01 / 31
MONTH DAY
41
13.B. DATE OF BIRTH
3B. DATE OF BIRTH
3. A. AGE
4. EMPLOYMENT
A. USUAL OCCUPATION Bank Teller
B. TYPE OF iNDUSTRY OR BUSINESS M & T Bank
15. PLACE OF BIRTH Bronx. New York
(CITY. ST A TElCOUNTRY IF NOT USA)
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A. USUAL OCCUPATION Plumber ~ ~
B. TYPE OF INDUSTRY OR BUSINESS Poughkeepsie City Sch.
5. PLACE OF BIRTH (crrM~~MPct~~w~ff ~~ew V ork
6. FATHER
A. NAME John Autorino
B. COUNTRY OF BIRTH l J ~ A
7. MOTHER
A. MAIDEN NAME 6arbar-a Wright
B. COUNTRY OF BIRTH II ~ A
8. NUMBER OF THIS MARRIAGE ")
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
....
. B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE. .W, O. ANNULMENT (220 DEATH
C. DATE LAST MAR';I~GE E~~~~~' ." .--- UL 16/ 003
MONTH v' DAY
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 SPSUSE
01/16/2003 POUQhkeepsie, N Y 0 0
o 0
o 0
o 0
t no legal impediment exists
16. FATHER
Dominick Di Chiaro
B. COUNTRY OF BIRTH USA
A. NAME
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Anna Nipro
USA
2
18. NUMBER OF THIS MARRIAGE
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH 0
~
DEATH
1
.,
(2) 0 DEATH
2004
YEAR
YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? OS 11)/
MONTH DAYJ
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NeT
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
a;
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o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
Y know edge and belief that the information I provided is true
21. SIGNATURE OF GROOM ~
01/05/2005
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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
by New York Domestic
r-^-.
{ SEAL }
'-.t-I
NAME (PRINT)
DATE
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 'Dl.t Tr.j,~c;.
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF J TOWN OF c.., VILLAGE OF
,
SPECIFY 8sT P,shlLJlI
,3 ~LI
DS
1722-
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) ;J,'ch(JrctS VQ,.('rn ,"
SIGNATURE ~ 01.< ft,,-"..,.1.A. 1"b.t/' .I'LI'~
-