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COUNTY
CITYfTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~ p Raffaele .IR
MIDDL CURRENT SbRNAME
~1",.&;.r-U..IooI."''''''''''"
(THIS SPACE FOR STATE USE ONL Y)
Dutch!!!..
Wappinger
1~
'K1
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
AlliAnn ~ FnrrP.Kt
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
1. A. FULL NAME
FIRST
A. NAME .1naP.ph Paul Rsdfaele
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME
i:dwin AlhP-rt S;1V1'P-!IIt
II SA
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
B. COUNTRY OF BIRTH
Debra Marl. Ecldc
USA
1
CynthIa AnA RlQhlrcaon
.....SA
1
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
.0 II
DEATH
DEATH
000
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (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
o
o
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (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
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) saF SPOUSE
o
o
o
is true and that I decl
23. SUBSCRIBED AND SWORN T. BEFORE ME
SIGNATURE OF TOWN OR C TV CLERK ~
This license authorizes the marriage in New York St
Relations Law ~11 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE MIn.-"Y7n04
by New York Domestic
,-^-..
{ SEAL }
'-v-'
YEAR
MONTH
YEAR
NAME (PRINT)
TIME
MONTH
1~~
05
04
07
02 2004
5T E
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
~ CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNn-Du:r~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFYWapPJl'(~~ ~J1 '!.
NAME (PRINT)
SIGNATURE ~