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COUNTY
CITYfTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
Dutchess STATE OF NEW YORK
WaDoinaer DEPARTMENT OF HEALTH
1368 AFFIDAVIT, LICENSE and
43 CERTIFICATE OF
"DUPLICATE"
Or ina1 Lost MARRIAGE
FROM THE GROOM
David P. De Vito
FIRST MIDDLE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L
o SUPPLEMENTAL FILE
FROM THE BRIDE
Larissa Longhi
FIRST MIDDLE
CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
CURRENT SURNAME
D. STREET ADDRESS
E. IS RESIDENCE WITHIN lIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 27 3B. DATE OF BIRTH IlK
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE De Vito
(OPTIONAL. SEE REVERSE) 105-72-9397
D. SDCIAL SECURITY NUMBER
12. RESIDENCE A. N Y B Dutchess
(STATE) J . (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY East Fishkill
ZIP 1259 D. STREET ADDRESS 12 Shadow Lane
o YES 0 Nt E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
2&' 1 7i. A. AGE 27 13.B. DATE OF BIRTH 02/
YEAR MONTH
12533
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 051 72 3461
D. SOCIAL SECURITY NUMBER - -
2. RESIDENCE A. N Y B. Dutchess
(STATE) ui (COUNTY)
C. CHECK ONE 0 CITY 0 T01VN 0 VILLAGE
~~~CIFY Fishkill
5410 Boulder Way
ZIP
o YES 0 No""
24 / 1978
DAY YEAR
DAY
MONTH
14. EMPLOYMENT
4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Dover High School
15. PLACE OF BIRTH Tarrytown, New York
(CITY, STATE/COUNTRY IF NOT USA)
A USUAL OCCUPATION Financial Analyst
B. TYPE OF INDUSTRY OR BUSINESS General Electric
5. PLACE OF BIRTH Yonkers. New York
(CITY, STATEICOUNTRY IF NOT USA)
16. FATHER
A. NAME
Richard Longhi
USA
6. FATHER
A. NAME
Albert Daniel De Vito. Jr.
USA
B. COUNTRY OF BIRTH
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Maryann Eaan
USA
1
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
.Ioanne Mary Monaco
USA
1
18. NUMBER OF THIS MARRIAGE
8. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULlED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
YEAR
o 0
o 0
o 0
o 0
e that no legal impediment exists
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o 2ND
o 3RD
o 4TH
nd belief that the Information I provided is true
21. SIGNATURE OF GROOM
06/01/200~
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23. SUBSCRIBED AND SWORN TO B ORE ME
SIGNATURE OF TOWN OR CI CLERK ~ DATE
This license authorizes he marriage in New York State the bride and groom named above by any person authorized by New York Domestic
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 CLlERK 25. A. SOLEMNIZATION PERIOD BEGINS
John C. Masterson
AM
03i~
~
{ SEAL}
'-.,-I
NAME (PRINT)
TIME
MONTH
SIGNATURE ~
MAILING ~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
10 CIVIL
TITLE ~l!4-l.\ r~HliC' -:Wi'~-+
DATE d v-hA 3 ;tooo
\. '
SPECIFY (! ~ H s k)L \'11
NAME (PRINT)
SIGNATURE ~
DOH.98 (11/98)
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