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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~~~E" Nl9iA. '~~ENT SURNAME
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNAl1JRE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit in New 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
COUNTY Dutchess
CITY(TOWN Wappinger
~~J~~c~ 1~
~5~~J~R 23
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SU RNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER ()Qf\..RR.A333
2. RESIDENCEA.~)Yodf B.~
C. CHECK ONE 0 CITY !::inOWN 0 VILLAGE
AND ,..a-.
SPECIFY ~PPrv.r
D. STREET ADDRESS 98 MAe FarlAnll ~nAd ZIP 1 ?6M
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES []II' NO
3. A. AGE 23 3B. DATE OF BIRTH ~ / ~ / y1iB1
4. EMPLOYMENT
A. USUAL OCCUPATION Maintenance WoJ:k:er
B. TYPE OF INDUSTRY OR BUSINESS TO"AIn Of Wappinger
5. PLACE OF BIRTH
, A
6. FATHER
A. f:'J"'ME Paul Neglia Sr..
B. COUNTRY OF BIRTH USA
7. MOTHER
.... MAIDEN NAME Betty !-.FIne Pleken
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRI...GE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS M...RRI...GES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
B. HOW DID L,6.ST MARRIAGE END? (3) 0 DIVORCE
C. D'" TE LAST MARRI...GE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. "'RE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DIlITE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
o
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U)
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{ SEAL }
'-.-'
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
-
:SIAI~ t'IL~ NUMtst:H
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
M16~fB L- flEMn~RENTSURNAME
--.l
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Neglia
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 12D-6ft.R1\M
12. RESIDENCEA. NMEYm:k: B. ~ess
C. CHECK ONE 0 CITY D~OWN 0 VILLAGE
AND ...,_.
SPECIFY v_ppngp.r
D. smEET ADDRESS 26 Montfort Poed
. 13. A. AGE 23
14. EMPLOYMENT
A. USUAL OCCUPATION Teacber's Aide
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH ~~ r~)
16. FATHER
ZIP 12590
YES Mo
/1.1
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
M~ /~
13.B. DATE OF BIRTH
A. NAME William Jacob Reinig
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME ROSH"" Michele A.1Z8no
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
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
o
o
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 0
o 0
o 0
o 0
al imp~dim~nt exists
22. SIGNATURE OF BRIDE ~
TIME
MONTH
YEAR
YEAR
04
06
06
04 2004