138
J
!z
w
Ul
W
'"
Cl
..J
:::>
o
J:
Ul
Z
o
~
a:
Iii
Ci
'W
a:
w
Cl
<(
ii:
a:
<(
::i
IL
o
W
!;(
o
u:
~
w
o
w
a:
w
J:
~
Ul
Ul
w
a:
Cl
Cl
<(
>
IL
U
w
n.
Ul
.1
\ )
"-./
~:i:z
:::>!::Q
>-~>-
:l!~~
>-WZ
Ul..J::i
:::>ow
::iCl5
>-ZUl
Z-
~~~
ita",
0>->
w~C3
bt5.n
zg~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York tate of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies w' in New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license IS to be used onl for the ur ose of a second or subsequent ceremony.
24. TOWN OR CllY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY 0l.Itd\M!i
,CITYITOWN WAppI.,
DISTRICT 13RR
NUMBER
~5~I:J~R 1~
1. A. FUll NAME
~ J VUENTSURNAME
FIRST
n.
N
B. BIRTH NAME, IF DIFFERENT U"baw
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 ~0586
2. RESIDENCE A.~.;v'nrtc B. ---\JAMf
C. CHECK ONE D CllY [il'TOWN D VILLAGE
AND
SPECIFY ShsIwIa'9Jnlc
D. STREET ADDRESS 1M \AIaAtI A~ ZIP 125AR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? DYES cY NO
MJU / 19 / y1i10
3. A. AGE 3]
4. EMPLOYMENT
A. USUAL OCCUPATION CorrAr.fior- Offi~
B. TYPE OF INDUSTRY OR BUSINESS 0 C S 0
5. PLACEOFBIRTH~~19rk
6. FATHER
A. NAME Ali~ ~lIgJllbti'_
B. COUNTRY OF BIRTH PodIlgeI
7. MOTHER
3B. DATE OF BIRTH
A MAIDEN NAME Priscilla MagaIhHI
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1
DEATH
o 0
B. HOW DID lAST MARRIAGE END? (3) CJ'bIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 04/ M / ')Ntn
MONTH OAr ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? [JllItES D 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
~Gosheft. NewYodc
a:
w
'"
:::;
::>
z
c
z
..
...
w
w
a:
Ii;
21. SIGNATURE OF GROOM ~
w
(J)
Z
W
o
:J
~
{ SEAL }
'-.,-I
NAME (PRINT)
SIGNATURE ~
MAILING ADpRESS
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~Ie BiaR~mNT SURNAME
..J
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~JN~~~~~~e~~SE)\&!98d
D. SOCIAL SECURITY NUMBER Q5&.62..S44D
12. RESIDENCE A. N1M41ot:k B. Q~esl
C. CHECK ONE D CITY [J,;IrOWN D VILLAGE
AND \A.... .
SPECIFY v_ppager
D. STREET ADDRESS 64 Robert Lan. ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? DYES [lI' NO
13. A. AGE 30 13.B. DATE OF BIRTH McIM / ~ ~!M~
14. EMPLOYMENT
A. USUAL OCCUPATION Hair Stylist
B. lYPE OF INDUSTRY OR BUSINESS Da-'es salon
15. PLACE OF BIRTH .~y'tiJkSA)
16. FATHER
A. NAME Michael Anthony Bianchini, Jr.
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Rose Marie DI Salve
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) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
D. . ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES D NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUEO AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
YEAR
D 1ST
D 2ND
D 3RD
D 4TH
Ie that the information I provided is true and that
o D
D D
D D
D D
declare that no legal impediment exists
. ,
22. SIGNATURE OF BRIDE ~
~~
USI: G ARENT NAME
DATE 1~
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
10f1'R1"111n
ZI
28. PLACE WHERE MARRIAGE O~URRED L
A. STATE NEW YORK B. 4i/1l/-f1 tJ. JJ
C. LOCATION OF CEREMO~Y
(CHECK ONE AN~IFY)
D CITY OF r:r;OWN OF D VILLAGE OF
SPECIFy!1;f!;-#r! (-{-If
10
07
12
05 2003
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
A E
27.lYYOF CEREMONY
oLE1' RELIGIOUS
9 D OTHER, SPECIFY
1 D CIVIL
w
~
o
u::
i=
a:
w
o
M 77E-~,-
SIGNATURE