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STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Yi
I
a.
N
STATE OF NEW YORK I
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME FIRST ~~~E::Iel F P~I b~~~NT SURNAME 11 A. FULL NAME FIRST Gab~~bt~ Mana C~S~E~PsURNAME
B BIRTH NAME, IF DIFFERENT t= mAry Mi~hRP.l PAIIIc:.e B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT ~ rusl"alzo
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE r::achon
(OPTIONAL _ SEE REVERSE) (OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 11 R..~o..~7 A~ D. SOCIAL SECURITY NUMBER 115-42-4673
2. RESIDENCE A. N(S)';.TE) B. ~P.c:.c:. 12. RESIDENCE A. N ;1;ATE) B. qb~s
C CHECK ONE D CITY [Y" TOWN D VILLAGE C. CHECK ONE D CITY o;rOWN D VILLAGE
AND W . AND W .
SPECIFY 8pp1nger SPECIFY 8pp1ngp.r
D. STREET ADDRESS 30 Sherwood Heights ZIP 12590 D. STREET ADDRESS 30 Sherwood Heights ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES rJ' NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES [J' NO
3. A AGE 65 3B.DATEOFBIRTH MOQi / ~ / W9 13.A AGE 64 13.B.DATEOFBIRTH M~ /~ly ~~At
4_ EMPLOYMENT 14. EMPLOYMENT
A USUAL OCCUPATION Electrician A USUAL OCCUPATION n@.!!:;ignp.r
B. TYPE OF INDUSTRY OR BUSINESS Metro North B. TYPE OF INDUSTRY OR BUSINESS Self-emplnyed
5. PLACEOFBIRTH ~~~A~~~~JfvII~~oN,~YQrk 15. PLACE OF BIRTH ~g~~~~JM~~FNt\~\\!)
6. FATHER 16. FATHER
A NAME Eme'Y Peluse. A NAME Bruno F=ru~CRI,.o
B. COUNTRY OF BIRTH USA B. COUNTRY OF BIRTH Italy
7. MOTHER 17. MOTHER
A MAIDEN NAME Mildred Heisler A. MAIDEN NAME Maria Ser~na
B. COUNTRY OF BIRTH USA B. COUNTRY OF BIRTH It::lly
8. NUMBER OF THIS MARRIAGE 2 lB. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT DEATH
1 0 0 0 0 1
B. HOW DID LAST MARRIAGE END? (3) Cf'DIVORCE (3) D ANNULMENT (2) D DEATH B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D"fiEATH
C. DATE LAST MARRIAGE ENDED? 12/ 10 / 1990 c. DATE LAST MARRIAGE ENDED? Q1 / 25 / H.~'
MONTH DAY YEAR MONTH '91' Y YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES D NO D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES [YNO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 12/1011990 Poughkeepsie, NY cJ' D 1ST D D
2ND D D 2ND D D
3RD D D 3RD D D
4TH D D 4TH D D
I, being duly sworn, depose and say, that 10 the best of my knowledge and belief thaI the information I provided is true and thaI I declare thaI no legal impediment exists
as 10 my righlloenter into the marriage stale. ~ ~ . r.
21.SIGNATUREOFGROOM~ ~. 22.SIGNATUREOFBRIDE~ -~ ~
\ USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO BEFORE ME DATE 09,nr'/2004
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 by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D 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
{ } NAME (PRINT) Gloria J.
e TIME MONTH
SEAL SIGNAl'n"R
'-v-I MAI~~fdai~ AM 09
STREET ZIP 03:21 PM
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
COUNTY Dutchess
CITYfTOWN \Nappinger
~~J~~CRT 13l=iR
~5~I~J~R 1 ?R
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YEAR
1~
28. PLACE WHERE MARRIAGE OCCUR~_
A. STATE NEW YORK B. COUNT~~
C. LOCATION OF CEREMONY
(CHECK ONE AND ?IFY)
D CITY OF ~WN OF D VILLAGE OF
SPECIFY #I\11A ~~ut-
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NAME (PRINT)
SIGNATURE~
DOH-98 (11198)
.
SIGNATURE ~