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COUNTY
CITYfTOWN
DISTRIC'I
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MI~8r" J. ~"ME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
~d~MS
Wappnger
1368
40
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Qmlise M. BiBl"'~E
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
&ahfHmWl . Madadflllli
090-56-9482
B. (CO~1C2Ia
VILLAGE
071 72 9101
B. (cou~ess
o VILLAGE
12. RESIDENCE A. ........... rt
(~I"~V'. I 0 K
C. ~~5CK ONE 0 CITY 0 TOW~ 0
SPECIFY Wappinger
D. STREET ADDRESS 8 SpIlt Tree DrIve ZIP 1259C
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO .;
A. AGE _ 13.B. DATE OF BIRTH / 0/ "9'7
,,;:1 MONTH ag- DAY :r- YEAI) 'I .
14. EMPLOYMENT
(STA~tJlAI Yofk
o CITY 0 TO"
WIIppiRger
g D. STREET ADDRESS 8 Sj:lIlt Tr.. DAve ZIP
U') E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO';
~ 3. A. AGE ~4 3B. DATE OF BIRTH L _L 1
o:n MONTH ~ DAY 02"' YEAR
2. RESIDENCE A.
C. CHECK ONE
AND
SPECIFY
4. EMPLOYMENT
PGliGe OIIieer
B. TYPE OF INDUSTRY OR BUSINESS CIty Of Yenkers
5. PLACE OF BIRTH ~I"- ........ VII"III'II!
(CITY. ",~~g",""'I"'_USl\""'"
6. FATHER
A. NAME , RiGhard A. MadaffaFi
B. COUNTRY OF BIRTH
A. USUAL OCCUPATION Di_bled
B. TYPE OF INDUSTRY OR BUSINESS
A. USUAL OCCUPATION
USA
15. PLACE OF BIRTH (CITY. BremctllNewMork
16. FATHER
A. NAME Michael Gjanll~
B. COUNTRY OF BIRTH Italy
17. MOTHER
A. MAIDEN NAME
II
~ -
~!
uQ
.
~
*=
Q.
C/)
cO
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
B. COUNTRY OF BIRTH
Laura De Polo
USA
1
Jo Anne CaWello
USA
1
1 B. NUMBER OF THIS MARRIAGE
B. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
(2) 0 DEATH
o
(3) 0 ANNULMENT
/ /
o
o
(2) 0 DEATH
'0
B. HOW 010 LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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
YEAR
YEAR
MONTH DAY
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
o 0
o 0
o 0
o 0
pediment exists
o
o
o
o
o
o
1ST
2ND
3RD
21. SIGNATURE OF GROOM ~
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:;
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State and groom named above by any person authorized by New Yo
Relations Law ~11to perform marriage ceremonies within N 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
~
{ SEAL}
'-v-I
NAME (PRINT)
TIME
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
27. TYPE OF CEREMONY
RELIGIOUS ~IVIL
A.
C.
rr
29. OFFICIANT
NAME (PRINT)
o VILLAGE OF
. \e\
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) \j)lA6'\ I, 0 \J2 \..Lr' "\'
':D~\~\\t ~
SIGNATURE ~