054
....
z
W
rJ)
W
m
9
::J
o
:r:
rJ)
z
o
;:::
."
II:
....
rJ)
a
W
II:
W
Cl
."
a:
II:
."
::1
u.
o
W
....
."
o
11:
;:::
II:
W
o
W
II:
W
:r:
:;:
rJ)
rJ)
W
II:
o
o
."
>-
u.
(j
W
n.
rJ)
....
w
W
lr
....
(J)
~~~
....:;:....
W ."
lr"'N
j-ffiz
rJ)-,::1
::JOW
~"O
....zrJ)
z-
~~~
~o(J)
0....>-
Ui~C3
b~U)
Z::i~
COUNTY Dlltche-ss
CITYfTOWN V\.Iappinger
~~~~~~T 1368
~G~I~J~R 54
::s I A I t: UI- Nt:W YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
RQtl~t~ Francis t>JWImURNAME
FIRST
~ I A II: t"ILt: NUMtlt:.H
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~hY M. HabimENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
c.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT Sisia
c. SURNAME AFTER MARRIAGE PatsJia
(OPTIONAL - SEE REVERSE) ~
D. SOCIAL SECURITY NUMBER 055 54 9772
B. Q~~
[]~DWN [] VILLAGE
099- 32-1826
2. RESIDENCE A. I\!SXTE) B. g~8SS
C. X~5CK ONE [] CITY Q/'TOWN [] VILLAGE
SPECIFY Wappiner
D. STREET ADDRESS 27 Fieldstone BOII'eovard
12. RESIDENCE A. N V
(~ATE)
C. CHECK ONE [] CITY
AND
SPECIFY Wappir:ler
D STREET ADDRESS 27 Fieldstone Boulevard ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? [] YES [if NO
Mo1~ / Q~ ~~~
12590
YES [i' NO
/ y1~3
13.8. DATE OF BIRTH
ZIP
E. IS RESIDENCE WITHiN LIMiTS OF CITY OR INCORPORATED VILLAGE? []
3. A. AGE 61 3B. DATE OF BIRTH MO"Q? / DO
4. EMPLOYMENT
A. USUAL OCCUPATION Personal Trainer
8. TYPE OF INDUSTRY OR BUSINE$S All Sport
5. PLACE OF BIRTH ~mg~uCiWF ~~ York
6. FATHER
A. NAME Nicholas Paglia
8. COUNTRY,OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Elena Yannuzzi
8. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
13. A. AGE 44
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
8.. TYPE OF INDUSTRY OR BUSINESS t^!.app. Cntrl School
15. PLACE OF BIRTH -i~~MY'{~SA)
16. FATHER
A. NAME Ralph Sisis
8. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME .^dlne Safube
8. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
100
B. HOW OlD LAST MARRIAGE END? (3) c:Io'fJlVORCE (3) [] ANNULMENT (2) [] DEATH
C DATE LAST MARRIAGE ENDED? 02/ n3 / ?M3
MONTH DA"f' ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? [JoIIfES [] 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
1ST 02103!2003 Poughkeepsie, N Y
2ND
3RD
4TH
I, being duly sworn, depose and say, t
as to my right to enter into the marri e stat
21. SIGNATURE OF GROOM ~
1 0 0
B. HOW DID LAST MARRiAGE END? (3) Oi!lIVORCE (3) [] ANNULMENT (2) [] DEATH
C. DATE LAST MARRIAGE ENDED? MONTH 10 / D~3 / ~1
D. ARE ANY FORMER SPOUSE(S) ALIVE? []o.,If'ES [] 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
1 ST 10/2312001 Poughkeepsie, N Y
2ND
3RD
4TH
t the information I provided is true
[]
[]
[]
w
en
z
w
()
:J
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of t e bride and groom named above by any person authorized
Relations Law gll to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
[] 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
,-"-.,
{ SEAL }
"-y-I
NAME (PRINT)
MONTH YEAR
TIME
MONTH
YEAR
06
08
2
08 06 2004
ZIP
1)( CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY i)ut~..s
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
[] CITY OF [] TOWN OF )( VILLAGE OF
SPECIFY \rJ o..~,t'\~Q..C'.s f 6..\\'"
SIGNATURE ~