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COUNTY Dutchess
CITY/TOWN Waopinaer
~~J:~CRT 1368
~5~I~J~R 73
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Luigi MA77uoccolo
MIDDLE CURRENT SURNAME
ti I A I t:. t"1I..t: NUMtU:.t1
(THIS SPACE FOR STATE USE ONL Y)
~
L 0 SUPPLEMENTAL FILE
11, A. FULL NAME
FROM THE BRIDE
~r.ott
CURRENT SURNAME
1 A FULL NAME
Wend)! A
FIRST MIDDLE
8, BIRTH NAME (MAIDEN NAME), IF DIFFERENT ~r.n1t
C. SURNAME AFTER MARRIAGE MA77llor:r.nln
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1??~),.S14h
12. RESIDENCE A. N XTATE) B. f)1J!UJ~$f'1O;.
C, CHECK ONE 0 CITY CY"TOWN 0 VILLAGE
AND W .
SPECIFY appmger
o STREET ADDRESS 12 Evergreen Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS DF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 48 13.8. DATE OF BIRTH M~H /~Y .{9~
FIRST
8. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 071 6n ':i46':r
D SOCIAL SECURITY NUMBER -. ~~-_..!
2 RESIDENCE ANY B Dutchess
(STATE). (COUNTY)
C CHECK ONE 0 CITY I!'f' TOWN 0 VILLAGE
~~~CIFY Wappjnaer
o STREET ADDRESS 12 Evergreen Drive
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 1!l' NO
0:\ /1? / 1 ~1
MONTH DAY YEAR
3. A. AGE 43
38. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Retired
8. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Yonkers. New York
(CITY, ST A TElCOUNTRY IF NOT USA)
4. EMPLOYMENT
A. USUAL OCCUPATION Auto Body Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Baccari's Auto Body
5 PLACE OF BIRTH Bronx. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Rafele Mazzuoccolo
B. COUNTRY OF BIRTH ItalY
7. MOTHER
A. MAIDEN NAME Anna Cipolla
8. COUNTRY OF BIRTH Italy
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
16. FATHER
A. NAME \Mnslow Scott
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Anne "'arie Lento
8. 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
DEATH
o
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
c. DATE LAST MARRIAGE ENDED?
(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
MONTH QA Y 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
a:
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o 1ST 0 0
o 2ND 0 0
o 3RD 0 0
o 4TH 0 0
lief that the information I provided is true and that I declare that no legal impediment exists
". ",,,^'""' o~'"''' ~ \. ~.JSi;t:'
DATE 07106(2004
by New York Domestic
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say,
as tD my right to enter intD the m~i
21. SIGNATURE OF GROOM ~ /
23. SUBSCRIBED AND SWORN BEFORE ME
SIGNA lURE 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
Relations Law 911 to perform marriage ceremonies within 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 subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25 A SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) loria ~. Mo . TIME MONTH YEAR MONTH
SEAL SIGNATURE' DATE 07/06/2004
'-y-I ~T!~U&ush ~TYrrO~falls NrTAT~2590 ZIP 11:00~~ 07 07 2004 09
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 00 RELIGIOUS
OATE AND AT THE TIME AND
PLACE INDICATED 90 OTHER, SPECIFY
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YEAR
04 2004
1~ CIVil
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNTY D-v-T~Q.~
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY F\~h'~..\~\
NAME (PRINT)
SIGNATURE ~