110
>-
Z
W
rJJ
W
lD
o
.....
::l
o
J:
rJJ
Z
o
;::
C[
II:
>-
rJJ
a
w
II:
W
Cl
C[
a:
II:
C[
::!
u.
o
w
5
u::
;::
II:
W
()
W
II:
W
J:
l:
rJJ
rJJ
W
II:
o
o
C[
it
13
w
a.
rJJ
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Anthony Joseph Datalo
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN WaDdnaer
~~~:kG:rJ 1388
~5~I:J~R 110
1. A. FULL NAME
FIRST
a.
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE Bossio. DaloIo
(OPTIONAL. SEE REVERSE) ~~-8280
D. SOCIAL SECURITY NUMBER \K~
2. RESIDENCE A. Washinatan B. Kina
(STA~ ~)
C. CHECK ONE r'!I' CITY 0 TOWN 0 VILLAGE
~~CIFY Seattle
D. STREET ADDRESS 'f309 ~ Place N. E. ZIP 98115
E. IS RESIDENCE WITHIN LiL'~ bF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE 26 3B. DATE OF BIRTH 10 / D? / 1Q77
MONTH DAY . YEAR
I
STATE ALE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
t-
:>
c(
c
,dt
c(
4. EMPLOYMENT
A. USUAL OCCUPATION student
B. TYPE OF INDUSTRY OR BUSINESS U. or WIshInaton
5. PLACE OF BIRTH l'hImouth. M8Sl8Chusetts
iC~:S;ATEICOUNTRY IF NOT USA) .
6. FATHER
A. NAME Joseph Francis DaloIo
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Elaine Martha Me laughlin
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
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Debra Ann Bossio
MIDDLE CURRENT SURNAME
-1
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Bossio . DatoIo
(OPTIONAL. SEE REVERSE) 1""-~0022
D. SOCIAL SECURITY NUMBER ~
12. RESIDENCE A. WasThington B. Kina
(STATE]. (C~'rv)
C. CHECK ONE [YCITY 0 TOWN 0 VILLAGE
~~~CIFY Seattle
D. STREET ADDRESS 6809 ~ Place N. E. ZIP 98115
E. IS RESIDENCE WIT~rR;RTS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13; A. AGE 77 13.B. DATE OF BIRTH M~ / \9v --1m
14. EMPLOYMENT
A. USUAL OCCUPATION student
B. TYPE OF INDUSTRY OR BUSINESS Bastyr University
15. PLACE OF BIRTH ~~~A~~Y~U}:~rk
16. FATHER
A. NAME Ronald John Bossio
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME I nraftA 011 "ArM
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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
II:
W
III
::;
:::J
Z
o
z
C[
....
w
W
II:
Iii
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
nowledge and belief t at the information I provided IS true ?;)d that I declare that no legal impediment exists
\ 22. SIGNATURE OF BRIDE ~ -L4h'C ..4.......~
, u~
09101/2004
.
23. SUBSCRIBED AND SWORN TO BEFORt: ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies with New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subse uent ceremony.
~ 24. TOWN OR CITY CLE~K 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Gloria J.
{ ~ ~
SEAL SIGNATURE ~ 09ID112OO4
'-v-I MA~.dIibuBh NY 12590 11:57AM 09
STREET !TOWN ATE 21 P PM
~~~R~:R~~~ 6~O~~N~~E~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR o. RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND "L.. AM to~ l'ct>. Z
PLACE INDICATED. "~ ...."r. T 00 9 0 OTHER, SPECIFY
w
U)
Z
W
(J
::i
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY. ~4 Let-I F>S'
~~~
>-l:>-
~~~
>-wZ
rJJ.....::!
::l()W
::!Cl5
>-ZrJJ
z-
~~~
~ocn
0>->-
w~~
b~"'
Z:J;!;
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF . TOWN OF 0 VilLAGE OF
:t>1.A"Tc \i ~> M ~ r"0 l<
SPECIFY
f-(.UI.\""c- qb
ZIP fI5ij\-1;;\l-L- (V.
31. WITNESS TO CEREMON\ _
NAME (PRINT) K 'f\ G"T )
SIGNATURE ~