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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
UimAP.I A I=AnP.Ili
MIDDLE CURRENT SURNAME
COUNTY Dutch--
CITYiTOWN w.pploger
. UISTRICT 1~
NUMBER
~5~I~J~R 127
1. A. FULL NAME
FIRST
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) ....~.... ~ ..............
D. SOCIAL SECURITY NUMBER ~~
2. RESIDENCE A. ",.)Ynrk B. ~
C. CHECK ONE 0 CITY rYrOWN 0 VILLAGE
~~~CIFY EIiIRt FiKhkil1
D. STREET ADDRESS 75 Palen Road ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE ~ 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION MliRnn
MO
B. TYPE OF INDUSTRY OR BUSINESS Or ~ MllICt\nAry
5. PLACE OF BIRTH Klnft!Itftn. Nf!lW Vt'd'lt'
~o't""U~
6. FATHER
A. NAME PAnRr.eJJ l J KA7n1iAK
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME M"I Michele Mortorlno
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Andrea M Tr8bu~
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE l=anP-lli
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 058-74-f1GQ5
12. RESIDENCE A. ~lnrk B. qi::~IP-Ra
C. CHECK ONE 0 CITY 0 TOWN ~ILLAGE
~~CIFY Wappingers FallK
o. STREET ADDRESS ~ s. MlI!lSIer Avenue ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? cY'VES 0 NO
13. A. AGE 23 13.B. DATE OF BIRTH "t 4 / 4~ dQRl1
MO~T~~ ~
14. EMPLOYMENT
A. USUAL OCCUPATION Cleric&l
B. TYPE OF INDUSTRY OR BUSINESS Care Core NAtIonal
15. PLACE OF BIRTH ~~ti!r' Vork
16. FATHER
A. NAME Mir.fUIel .Jude TrRbu~
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME SIIIyI"" Mede Palumbo
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
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
o 1ST 0 0
o 2ND 0 0
o 3RD 0 0
o 4TH 0 0
nd belief that the information I provided is true and that I declare that no legal impediment exists
I 22. SIGNATURE OF BRIDE~. 1J;t,lJ.J'.A-- ~<<.c.. L ~
USE CURRENT NAME
23 ~~;,[,.~~~DO~N-?o~~Ot~ ci~Bg~~i~E DATE D9I28I2OO4
This license authorizes the marriage in New York St e of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies withi ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is 0 be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
W
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{ SEAL }
'-v-I
TIME
MONTH
NAME (PRINT)
SIGNATURE ~ -
MAILING ADI?RESS
AM
03:17PM
09
.29
YEAR
YEAR
IP
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
STAT
27. TYPE OF CEREMONY
o bci RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED. ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
Ir,.. ()~
~:~ It)
29. OFFICIANT r.:, t". III ^ .1I1\.D n. J
NAME (PRINT) ~. .....;-1'\ ,vI. V'l ...... \J\ 0
SIGNATURE ~ j(f~:z. k.~
MAILING ADDRESS ./' .
J/ Cl f IV\- H:iYl > J.. Ctp p ) '1MI::. ~t=r;.L{ !:.
STREET CITYfTOWN7J
30 WITNESS TO CE~MONY~
NAME (PRINT) ~__o..'S::"<,tV-re
SIGNATURE~ P~d.D
nOH-AR l11/AR\
TITLE
DATE
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY"pU.f..l1,-.J.t. c-,
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~
VILLAGE OF
SPECIFY VV C4..f>? ~.", d ~V' 1= <J.. \"\ !:,
NAME (PRINT)
SIGNATURE ~