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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
SC4GI Vincent IJMM
I
STATE ALE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY DutehesS
CITYfTOWN V,..nger
DISTRICT ·
NUMBER ~ase
REGISTE
NUMBER sa
L 0 SUPPLEMENTAL FILE
11. A.
FROM THE BRIDE
FULL NAME MesllfI Arme CtlRtPBi
CURRENT SURNAME
CURRENT SURNAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~ ~-"
(OPTIONAL.SEEREVER~ -, ""
D. SOCIAL SECURITY NUMBER 051...eG--6137
12. RESIDENCE ANe\M~ B. O.U,sS
C. X~6CK ONE 0 CITY I; TOWN 0 VILLAGE
SPECIFY\fJBppi.....
D. STREET ADDRESB1&88 Route 8 AfA.. 5c
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
B. BIRTH NAME, IF DIFFERENT
.C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 04~9239
2. RESIDENCE A. ~ark B. ~
C. X~6CK ONE 0 CITY ~ TOWN 0 VILLAGE
SPECIFY VJeppinaer
D STREET ADDRESS 1688 Reule 9 Apt 6e ZIP 12&00
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES#] NO
3. A. AGE42 3B. DATE OF BIRTH _ /03y / 1S62
4. EMPLOYMENT
A. USUAL OCCUPATION 8eeUfIIr M.....
B. TYPE OF INDUSTRY OR BUSINESS \.'.Jar Bres. Med. ctr.
5. PLACEOFBIRTH~~'~
6. FATHER
13.B. DATE OF BIRTH
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13. A. AGE28
14. EMPLOYMENT
A. USUAL OCCUPATIONC8dIIIed NuI8lASJ .wlst8Rt
B. TYPE OF INDUSTRY OR BUSINESS"fM T'homplOA ......
15. PLACE OF BIRTH8....~X_ USA)
16. FATHER
R
A. NAMEltHIm8B C8BYGCi
B. COUNTRY OF B1RTtU S A
17. MOTHER
A. MAIDEN NAME P8trIela kit \~8A
B. COUNTRY OF BIRTtU S .~
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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A. NAME ChlHtes FIyRR
B. COUNTRY OF BIRTH USA
"
7. MOTHER
A. MAIDEN NAME Mary Ann Febbrelo
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) 0 DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
100
B. HOW DID LAST MARRIAGE END? (3)~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? -"A /.u:l /4ft04
MONTHW"'" 0"'" 1I;Ii!JljIf'
D. ARE ANY FORMER SPOUSE(S) ALIVE? IIPYES 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
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
o 0
o 0
o 0
o 0
provided is true and that I declare that no legal impediment exists
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1ST 0411811991 ~e. Na.Y-ork 0 " 1ST
2ND 0 0 2ND
~ 0 0 ~
4TH 0 0 4TH
I, being duly sworn, depose and say, that to the best 0 my knowledge and belief that the Information
as to my right to enter into the marri state. ~
21. SIGNATURE OF GROOM ~ .+.-ll
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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 Stat of the bride and groom named above by any person authorized
Relations law ~11 to perform marriage ceremonies within 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
"-y-I
YEAR
MONTH
YEAR
NAME (PRINT)
TIME
MONTH
DATE~
10:44:~ 06
ZIP
30
2005
08
28 2005
28. PLACE WHERE MARRIAGE OCCUR/")
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY
(CHECK ONE, AJD SPECIFY)
o CITY OF ~WNdD~r-_OF
SPECIFY ~ rj.~
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
~CIVIL
29. OFFICIANT
NAME (PRINT)
SIGNATUR
MAILING A D
'"
NAME (PRINT)
SIGNATURE ~
OOH-98 (11198)