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COUNTY Dutchess
CITY/TOWN WaPPinger
~~J:~~ 1368
~5~~J~R 32
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~~E Alan Di~~~URNAME
"JAIl: riLl: raUMgl:n
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
1. A. ruu. NAME.
11. A. FULL NAME FIRST A~~~'GY N Rivip~~NT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT ~iviP-77n
C. SURNAME AFTER MARRIAGE ni nnnsrtn
(OPTIONAL. SEE REVERSE) 05"'""""1,........
D. SDCIALSECURITYNUMBER -~~-~
12. RESIDENCE A. N V B. nlltl'h~
(STATE) ~)
C. CHECK ONE 0 CITY 0 TOWN [)IfVILLAGE
~~~CIFY Wappingers Falkl
D STREET ADDRESS 6 ,Fulton strAet Apt. 1 ZIP 125M
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES lY' NO
13. A. AGE 21 13.6. DATE OF BIRTH MOtl / ti "'~IP
RRST
..
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 2
D. SOCIAL SECURITY NUMBER 1 1.54-3565
2. RESIDENCE A. N Y 8. Outcltl'!!Ut
(STATE) (COU~
C. CHECK ONE 0 CfTY 0 TOWN [!" VILLAGE
;~CIFY Wappingers Falls
o STREET ADDRESS 6 Fulton street Apt. 1 ZIP 12590
E. IS RESIDENCE WITHiN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES rJi NO
3. A. AGE ~ 36. DATE OF BIRTH n".l / n7 / 4 Q74
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4. EMPLOYMENT
A. USUAL OCCUPATION Custodial Worker
B. TYPE OF INDUSTRY OR BUSINESS Arlington SchI. Sy!:t8m
5. PLACE OF BIRTH Corttentl New Vark
(CITY, STA~NTRY IF NOT USA)
6. FATHER
A. NAME Frank Oi Donalo
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Marcia A Entner
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
14. EMPLOYMENT
A. USUAL OCCUPATION l-Iol~e
8. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Ml Kl&N\ NII!Mf V ork
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Frank- RiviP.?7n
B. COUNTRY OF BIRTH USA,
17. MOTHER
A. MAIDEN NAME Nancy Frustaglio
B. COUNTRY OF BIRTH II S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) 0 DEATH
DEATH
()
o
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
6. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DAlE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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1ST
2ND
3RD
4TH
I, being duly sworn, depose an s
as to my right to enter into the
21. SIGNATURE OF GROOM .
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
, that to the best of my knowledge and belief that the information I provided is true and that I declare that no
estate. ..--=
o 0
o 0
o 0
o 0
impediment exists
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATlJRE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State 0 the bride and groom named above by any person authorized
Relations Law 911 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
,-'-.
{ SEAL }
'-v-'
NAME (PRINT)
YEAR
MONTH YEAR
TIME
MONTH
AM
PM
07
07 05 2005
05
28. PLACE WHERE MARRIAGE OCCURR~ _ "'-
A. STATE NEW YORK B. COUNTYO<\A, I 'tm
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /"
o CITY OF 0 TOWN OF tf'VILLAGE OF
SPECIFY IAJAfJP'~ M
SIGNATURE~
DOH-98 (11198)