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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~ RomAno
MIDDLE CURRENT SURNAME
COUNTY I"'h ..,.haec.
CITYfTOWN, \NAppi.r
~J~~f~ 136A
~5~I~J~R 121
1. A. FULL NAME
FIRST
8. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) ...n.. """864~
D. SOCIAL SECURITY NUMBER ~~-.;!
2. RESIDENCE A. New Vork B. DI Jtclv!stA
(si'A'i'Ej (COUNTY)
C. CHECK ONE 0 CITY DIIlItOWN 0 VILLAGE
AND ...1-.
SPECIFY vvnppnger
D. STREET ADDRESS 22 0 Alpine DrIve
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 28 3B. DATE OF BIRTH
ZIP 12590
DYES D"'NO
MON
4. EMPLOYMENT
A. USUAL OCCUPATION RIIR Operator
B. TYPE OF INDUSTRY OR BUSINESS N Y C Transit Authority
5. PLACE OF BIRTH (ir.~~T~ft:~Br"
6. FATHER
A. NAME .John Anthony Romano
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Helen COl.
B. COUNTRY OF BIRTH U $ 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
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
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 STA TE USE ONL V)
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Alison K. Carozza
MIDDLE CURRENT SURNAME
-.J
11. A. FULL NAME
FIRST
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Romano
(OPTIONAL - SEE REVERSE) nnD ~a~99
D. SOCIAL SECURITY NUMBER U~
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 IlIIbWN 0 VILLAGE
~~~CIFY East Fishkill
o STREET ADDRESS 76 Warren Ferm Road
12533
YES D"'NO
/1983
YEAR
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
01 / 22
MONTH DAY
13. A. AGE
71
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION CoBmotoloaist
B. TYPE OF INDUSTRY OR BUSINESS Eckerd
15. PLACE OF BIRTH ~~e. New York
(~rr~~~~ NOT USA)
16. FATHER
A. NAME Thomas A. Carozza
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME JAcqUAlIM ~k
B. COUNTRY OF BIRTH USA
1
lB. NUMBER OF THIS MARRIAGE
19. 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
1ST 0 0 1ST
2ND 0 0 2ND
~D 0 0 ~D
~ 0 0 ~
I, being duly SWDrn, depose and say, that to the best of my knDwledge and belief that the information I provided is tr
as tD my right to enter intD the m ia estate.
o 0
o 0
o 0
o 0
nD legal impediment exists
21. SIGNATURE OF GROOM ~
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{ SEAL }
~
22. SIGNATURE OF BRIDE ~
17f2004
DATE
authorized by New York Domestic
TIME
MONTH
YEAR
AM
01 :Q&.1
09
,0 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
l)v fc 1. t:: J..s
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~N OF 0 VILLAGE OF
SPECIFY lis A K, I ( Ii
SIGNATURE ~