037
COUNTY Dutchess
~ CITYrrOWN Wappinger
~~J~~C: 1 :388
~5~~J~R 37
0-
N
....
z
w
m
w
m
o
...J
:::J
o
:I:
m
z
o
~
a:
Iii
a
w
a:
w
Cl
<
1C
a:
<
::;
u.
o
w
....
<
o
u:
F
a:
w
o
w
a:
w
:I:
;;:
m
m
w
a:
o
o
<
>-
u.
<3
w
0-
m
tf:i:z
~~~ w
~~~ I-
....wz c:c
3<315 0
~~g LL
z-
n~t5 t=
itom a:
0....>- W
wlJlc5 0
b~LO
Z~~
1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
James Anthony: Glorioso, JR.
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
"I
L 0 SUPPLEMENTAL FILE
~
11. A. FULL NAME
FROM THE BRIDE
Anneliese Karla Ferreira Manneck
FIRST MIDDLE CURRENT SURNAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 051:7" ~"3
D. SOCIAL SECURITY NUMBER ~
2. RESIDENCE A. NY
(STATE)
o CITY 0 IIJtJWN
Poughkeepsie
D. STREET ADDRESS 1167 Dutchess Tumplke
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Glorioso
(OPTIONAL. SEE REVERSE) 48D11: ~959
D. SOCIAL SECURITY NUMBER __;:r ;org
NY B. Dutchess
(STATE) ~ (COUNTY)
o CITY 0 ~WN 0 VILLAGE
PouahkeeDSie
1167 Dutchess TumDlke ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 ~o
12/ 20 /1978
MONTH DAY YEAR
C. CHECK ONE
AND
SPECIFY
B. DutchM..ct
(COUNTY)
o VILLAGE
12. RESIDENCE A.
C. CHECK ONE
AND
SPECIFY
D. STREET ADDRESS
ZIP 12603
o YES 0 ~o
E. IS RESIDENCE WITHIN LIMITS OF CITY OR 1NCORPORATED VILLAGE?
3. A. AGE 28 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Store Manager
B. TYPE OF INDUSTRY OR BUSINESS starbucks
5. PLACE OF BIRTH ManhlllllCAt New York
(CITY, STA~F NOT USA)
6. FATHER
A. NAME James Anthony Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME fJ'\er~ CaI"'Gt'a
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
13. A. AGE ?S
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION Enpineer
B. TYPE OF INDUSTRY OR BUSINESS IBM CorD.
15. PLACE OF BIRTH Jaclara. Mato Grosso. Brazil
(CITY, STATEICOUNTRY IF NOT USA)
16. FATHER
A. NAME Reimund Manneck
B. COUNTRY OF BIRTH ~rm8nY
17. MOTHER
A. MAIDEN NAME Edith FArrelra Urna
B. COUNTRY OF BIRTH Brazil
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATIE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATlElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to th,best of my
as to my right to enter into the marriage state./"
. ,
21. SIGNATURE OF GROOM ~
1ST 0 0
2ND 0 0
3RD 0 0
~ 0 0
jef that the information I provided is true and that I declare that no legal impediment exists
r~~ '('{\~.
USE CURRENT NAME
0512412005
o
o
o
w
en
z
w
o
::::i
23. SUBSCRIBED AND SWORN TO BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the 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
Gloria J...MPrse
SIGNATU :/t ,0 .-C/ /?-<-'t'~ DATE 05124 TIME MONTH
MAlLIN ADDRfdCae 'n r Falls NY 12590 11:5111 05
STREET I ITO N STATE ZIP PM
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER. .
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR o"lil.. RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. ;;2 ~ "!-'I) (t)::5 C) r:; 9 0 OTHER, SPECIFY
YEAR
DATE
by New York Domestic
~
{ SEAL }
'-v-I
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY'^*'-""""""'-~I."
~. ~AC'_ ~ ^X!;^ "t
NAME (PRINT) ~ I ......V' . "-
SIGNATURE ~ ~ , ~
MAILING ADDRESS ... r-
I ~ti'V\~ 9- W ~ )'\1) !:. J-
STREET CITY 0 N
30. WITNESS
TITLE r'Y' :; .-t ~ )..
DATE -k1 ~ 1 a tlC 5""
N"'d. 1 ~s ~Z)
STATE
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFYW <.l.ff)lIIc..,~J~~"V. "A.,'I,
" 11 ~'\)
NAME (PRINT)
SIGNATURE ~