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COUNTY Dutchess
CITYrrOWN Wappinger
~~J~k1J 1368
~5~I~J~R 8
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thomas Anthony Schifini. JR.
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
S8VBn~~~ Nicole M~~~RNAME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~.hifini
D. SJgl~~I~~;ULR;T~E~U~~~~RSE) 126-68-0n3
12. RESIDENCE A. New York B DlJtch~
(ST ATE) (COUNTY)
C. CHECK ONE 0 CITY cYTOWN 0 VILLAGE
AND W .
SPECIFY Bpplnger
D. STREET ADDRESS 59 Robinson Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 20 13.B. DATE OF BIRTH 1n /ro 4QRd
MONTH .-roIY l'E'AR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 092 72 8313
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. New Yark B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY WappinQer
D. STREET ADDRESS 89 Robinson Lane
3. A AGE 70
ZIP 12590
YES ~ NO
/1~
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
1? /M
MONTH DAY
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Cleaner
B. TYPE OF INDUSTRY OR BUSINESS MAny Maldri
15. PLACE OF BIRTH ~I~~~O~~ ~~
16. FATHER
A. NAME Joseph M~hew
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Leslie Wiliams
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
DEATH
o
4. EMPLOYMENT
A. USUAL OCCUPATION stock Associate
B. TYPE OF INDUSTRY OR BUSINESS Gap Inc.
5. PLACE OF BIRTH Yonker's. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Thomas Anthony Schifini Senior
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Ma~gar8t t.Aery Hert
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
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 (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES D 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
0::
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1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~H 0 0 ~H 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the marria estate. \.. 1-.. -. ~a ~~.
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE,~ ~1 ~ -- ~ -~
'-./ USE CURR NAItI
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in te of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit i New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license i 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) Gloria J
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25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
,-'-.,
{ SEAL}
'-v-l
YEAR
TIME
MONTH
DAY
YEAR
MONTH
DAY
SIGNATURE ~
MAILING A!?DRESS
10:26 AM 02
PM
10
04
10 2005
ZIP
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS ~IVIL
9 0 OTHER, SPECIFY
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 'j)~ J fe1-L~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY i A Jrl tV / Ii 1r'f' ,.-'
