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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Vin/",..p.nt A I=;:lrln;l
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYITOWN Wappinger
~~~~~c~ 13fi8
~5~I~J~R 72
1. A. FULL NAME
FIRST
"-
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
O. SOCIAL SECURITY NUMBER OQ4-f\?-q~~?
2. RESIDENCE A. NY B. f!c1~p.r.::.'5
(STATE) c
C. CHECK ONE D CITY !if TOWN D VILLAGE
AND W .
SPECIFY applnger
o STREET ADDRESS 46 Amherst Lane
3 A. AGE 41
ZIP 12590
YES ~ NO
/lW3
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? D
M~ /tR
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION N Y S Correction Offir.P.r'
8. TYPE OF INDUSTRY OR BUSINESS N Y S Dept Of CnrrActlo~
5. PLACE OF BIRTH BrDnx New York
(CIlY, STATEICOUNTRY IF NOT USA)
6. FATHER
A. NAME Vincent Farina
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Anna \/aclavil<
8. COUNTRY OF BIRTH C7e~hncdovAkiA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) I!\" DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 12 / 15 / ?OO3
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? CfYES 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
12/1~I?OO3 Pnl_ghkeepsi~, NY
DEATH
o
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
...
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Mi~tJ.sI:~e R Sie\.tJlliNTSURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Sieving
c. SURNAME AFTER MARRIAGE ..sieving . F Qrino
(OPTIONAL. SEE REVERS,,} .
D. SOCIAL SECURITY NUMBER 129,,52.4429
12 RESIDENCE A. N'(STATE) B D~~lii
c. CHECK ONE D CITY [jI'TOWN D VILLAGE
AND Wa .
SPECIFY J'lPInger
o STREET ADDRESS 4S_Amhp.~ I An~ ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
JmH /2G.Y 19tii
13. A. AGE 34
14. EMPLOYMENT
A. USUAL OCCUPATION Pny,;ical Thprf'py Aide
B. TYPE OF INDUSTRY OR BUSINESS East Coast Pain Mgmt
15. PLACE OF BIRTH I (g{!?, ~~., I~~s~rnia
16. FATHER
13.8. DATE OF BIRTH
A. NAME Bn Ire .Ionn Si~ing
B. COUNTRY OF BIRTH II S /4
17. MOTHER
A. MAIDEN NAME Patricia Ann \-"Agand
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 3
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
2,
o
o
8. HOW DID LAST MARRIAGE END? (3) lY'DIVORCE (3) D ANNULMENT
C. DATE LAST MARRIAGE ENDED? OZ / n1
MONTH M.. 01
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
(2) D DEATH
/~3
01001997 POlIghkeepsie. NY
07f01f2003 Poughke€opsie, NY
cY D
L!I D
D D
D D
L impedi'!lent exists
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D D 2ND
D D 3RD
D D 4TH
ledge and belief that the information I provided is true
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK"
This license aulhorizes the marriage in New York State f the bride and groom named above by any person authorized
Relations Law 1111 10 perform marriage ceremonies within New York State, THIS LICENSE VALID IN NEW YORK STATE ONLY.
D 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
21. SIGNATURE OF GROOM ..
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DATE
by New
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON.
TIME
MONTH
YEAR
MONTH
YEAR
DAY
DAY
DATE 07/011?004
AM
12:34 PM 07
2
08
30 2004
02
ZIP
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TYPE OF CEREMONY
o lIl"'RELlGIOUS
9 D OTHER, SPECIFY
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED, I
A. STATE NEW YORK B. COUNTY ~
C.
930 0
~ o,,,,,,m ~ ~ ~L p-;<. ~}: Be.~
NAME (PRINT) ~ V. . J;;" ~ITLE "
SIGNATURE'" t::l::. DATE 0
M~rrPDR??/n"XJ&n} ~tdJ. M~M;4 fila ~ Ie{ ~
STRE T CITYITOWN ; . ST TE I ZI~
30. WITNESS TO CEREMONY 31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ..
nf'\J..I_QR (11JQR\
ITY OF D TOWN OF D VILLAGE OF
SPECIFY~~ ~
NAME (PRINT)
SIGNATURE ..