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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Gino Forgione, JR.
COUNTY DutcheSS
CITYfTOWN wappinger
. DISTRICT 1368
NUMBER
REGISTER 120
NUMBER
1 . A. FULL NAME
CURRENT SURNAME
FIRST
MIDDLE
"-
N
8. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) Dtr.:l-64-9421
D. SOCIAL SECURITY NUMB~
2. RESIDENCE A. New' ark B. Dutchess
(STATE)'; (COUNTY)
C. CHECK ONE WaD CITY D TOWN D VilLAGE
~~~CIFY pplnger on
D. STREET ADDRESS 12 0 \Nhlte ~ ve
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VI'tt4E?
3. A. AGE 25 3B. DATE OF BIRTH /
MONTH
1~
.;
25 Y/D1~7
DAY YEAR
ZIP
4. EMPLOYMENT
A. USUAL OCCUPATION Driver
B. TYPE OF INDUST~ .QR....s~.!t!5SS F~r~ :pI~
5. PLACE OF BIRTH \.OOIQ opnng. New TO
(CITY, STATElCOUNTRY IF NOT USA)
....
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41(
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ClLL
LL
41(
6. FATHER
A NAME Gino Forgione
B. COUNTRY OF BIRTH Italy
7. MOTHER
A. MAIDEN NAME Angela Marla Berarducci
B. COUNTRY OF BIRTH Italy
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORli CIVil ANNUtfENT
DEATb
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
(3) D ANNULMENT
/ /
(2) D DEATH
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES 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
D D
D D
D D
w
CJ)
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{ SEAL }
'-v-I
SIGNATURE ~
MAlll2[}1ftlIiM
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM TE'ffli~FiP'Stewart
~
11. A. FULL NAME
CURRENT SURNAME
FIRST
MIDDLE
8. BIRTH NAME (MAIDEN NAME), IF[>>IOF~~
"bI~ant:
C. S~S~JNi~~~~t~e~~SE) D83-86-29BO
D. SOCIAL SECU'tlfM~rrc Outdless
12. RESIDENCE A. (STATE) .; B. (COUNTY)
C. ~5CK ONEWapj:irijJeP TOWN D VilLAGE
SPECIFY 12 D V.,,1tt Gett Drive 12590
D. STREET ADDRESS ZIP .;
E. IS RESID~ WITHIN LIMITS OF CITY OR INCORPORATED VM'E? ~ YES 1919
13. A. AGE 13.B. DATE OF BIRTH / /
MONTH DAY YEAR
14. EMPLOYMENT
Waitress
"Inn" Credlable Caterers
B. TYPE OF INDUSTIJ~lti.SNew York
15. PLACE OF BIRTH
A. USUAL OCCUPATION
16. FATHER
A. NAME
(CITY, STATElCOUNTRY IF NOT USA)
James Michael stewart
USA
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
Margaret Ann O'neill
USA
1
B. COUNTRY OF BIRTH
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVOtfE CIVil ANNLQAENT
DEAT!)
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
2ND
3RD
D
D
D
D
D
D
by New York Domestic
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT~..q,~~
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF D TOWN OF ~ VilLAGE OF
SPECIFY W~?f'"V\ ().t..'Y"'> .,.-=-~ t 1 S
SIGNATURE