027
STATE OF NEW YORK I STATE FILE NUMBER I
:I COUNTY Outehess (THIS SPACE FOR STATE USE ONLY)
CITYfTOWf'o'. Wappinger DEPARTMENT OF HEALTH
gL~~~c: 1MB AFFIDAVIT, LICENSE and
~Q~\mR '27 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM TH~ GROOM FROM THE BRIDE
1. A. FUll. NAME Msdttv!w.1 nhrvall 11. A. FULL NAME ChiArA R Porr.n
FIRST MIDDLE CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNA.TURE OF TOWN OR CITY CLERK ~ DATE 0411312004
This license authorizes the marriage in New York Sta person authorized by New York Domestic
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 only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER ~~R-M1~
2. RESIDENCEA.~)Ynrlr B. ~
C. CHECK ONE 0 CITY Qll'rOWN 0 VILLAGE
AND
SPECIFY Hyde PArle
D. STREET ADDRESS 1~5 P1nAhrook OrlVA
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 30 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION SsJIf'R
B. TYPE OF INDUSTRY OR BUSINESS II~ployed
5. PLACE OF BIRTH
6. FATHER
A. NAME Jobn RobM ObrvBlI
B. COUNTRY OF BIRTH 1I S A
7. MOTHER
A. MAIDEN NAME .4.clelalde lAWs. COMqa
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
ZIP 125~
DYES [}ll'NO
DEATH
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(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
O. 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
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and sa , that to the best
as to my right to enter into the marri 118' allll\.. . -.
21. SIGNATURE OF GROOM ~
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Ohwell
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1~7L?M1
12. RESIDENCE A. ~Ernrlr B. ~f!!!iW
C. CHECK ONE 0 CITY 0 tltOWN 0 VILLAGE
AND W .
SPECIFY appngp.r
D, STREET ADDRESS ~ Nf!IW HA~MAek Road ZIP 125M
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~O
MO~ / QR /1~1~
13. A. AGE JS
14. EMPLOYMENT
A. USUAL OCCUPATION TPSI~P-r
B. TYPE OF INDUSTRY OR BUSINESS st. M8rt1n r'JA POITes Sct\
13.B. DATE OF BIRTH
15. PLACE OF BIRTH
16. FATHER
A. NAME Gil.lSePJ'P Girm Pcm-n
B. COUNTRY OF BIRTH Italy
17. MOTHER
A. MAIDEN NAME Sandra aemeelette aemaf.
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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o
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(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
22. SIGNATURE OF BRIDE ~
1ST
2ND
3RD
4TH
at the information I provided is true an
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o
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TIME
MONTH
YEAR
MONTH
YEAR
TE
04
14
06
12 2004
IP
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
r TE
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY "'D~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 'ls(TOWN OF 0 VILLAGE OF
SPECIFY E'~f =?t~Jtkl't /
TITLE~ ~1,~'.esT
DATE frpii.J dJ.S",o1...00c/-
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29. OFFICIANT
NAME (PRIN
NAME (PRINT)
SIGNATURE ~
DOH-98 (11I9B)
NAME (PRINT)
SIGNATURE~