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1. A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
steohen P, Marzovilla
FIRST MIDDLE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutchess
CITYrrOWN WaoDinaer
~~~~lf; 1368
~5~I~J~R 56
-.J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Wen~ C"..ohen
FIRST MIDDLE
CURRENT SURNAME
11. A. FULL NAME
CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE MAr7nviIlA
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 054-70-5RSO
12. RESIDENCE A. N Y B. nlJtl"h~Cl.
(ST ATE) i1:oUll'iY)
C. CHECK ONE 0 CITY cYrOWN 0 VILLAGE
AND W .
SPECIFY appnger
D. STREET ADDRESS 16 D Chelsea Ridge Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES rI NO
13. A. AGE 24 13.B. DATE OF BIRTH -g~TH ~AY ~1R
14. EMPLOYMENT
A. USUAL OCCUPATION Scheduling CoordinAtor
B. TYPE OF INDUSTRY OR BUSINESS Care Core National
15. PLACE OF BIRTH Bronx New York
(CITY, STA~ElCOUNTRY IF NOT USA)
16. FATHER
A. NAME Ted Elliot Cohen
B. COUNTRY OF BIRTH USA
17. MOTHER
A MAIDEN NAME Leone Merie VOfi.
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 055-74-8422
D SOCIAL SECURITY NUM8ER --
2 RESIDENCE A. N Y B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY rJ TOWN 0 VILLAGE
~~CIFY Wappinaer
D. STREET ADDRESS 16 D Chelsea Ridge Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES rt NO
11 /14 /1Q7R
MONTH DAY YEAR
3. A. AGE 26
38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Spread Ooerator
B. TYPE OF INDUSTRY OR BUSINESS Chemprene Co.
5. PLACE OF BIRTH PouahkeePSie. New York
(CITY. STATElCOUNTRY IF NOT USA)
6. FATHER
A. NAME Stephen Paul Marzovilla
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME TerMS C"..Adrminci
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
DEATH
o
DEATH
o
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
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
(MDNTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
o
o
o
o
o
o
1ST
2ND
3RD
21. SIGNATURE OF GROOM ~
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en
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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 the bride and groom named above by any person authorized
Relations Law !l11 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
{ } NAME (PRINT) Jo C. Maste
TIME MONTH YEAR
SEAL SIGNATURE ~. DATE 0612912OO5
'--- -J Mi\lI.Wq"IiP-IQIl~ 10'50 AM
-v- m MlcaU PDinaer Falls. NY 12590 ' 06
STREET CITYITOWN STATE ZIP PM
~~~R~~Ri~~~ IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY .'\ /'
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS ~CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 1.3 0 9 0 OTHER, SPECIFY
08
28 2005
MONTH
YEAR
30
2005
29. OFFICIANT
NAME (PRINT)
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY)t-(~ 1~
c. LOCATION OF CEREMONY
(CHECK O~ A,SPECIFY)
o CITY OF)il" TOWN OF 0 VILLAGE OF
SPECIFY /) )l1f 1" 1. r ('
SIGNATURE ~