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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
rlsIvirl A MsdthAwR
MIDDLE CURRENT SURNAME
COUNTY OutMft~
CITYITOWN WeppngM
~~J~~W 1368
~5~~J~R 121
1. A. FULL NAME
FIRST
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) ....A~17. ....17
D. SOCIAlSECURITYNUMBER ~_~__
2. RESIDENCE A. ~m)VQflr . 'B, ~MIR
C. CHECK ONE D CITY D TOWN [3Il'vILLAGE
~~~CIFY ~ppingP-AI FIIII"-
D. STREET ADDRESS ~ Clinton street
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
ZIP 12590
CJl'\-ES D NO
3. A. AGE 42
4. EMPLOYMENT
3B. DATE OF BIRTH
MO
A. USUAL OCCUPATION SAlf!A MAn.,.
B. TYPE OF INDUSTRY Of! BUSINESS l'~mblnAd lIfA 1M Co
5. PLACE OF BIRTH VftftltiMa ......, VnrIr
~otmr"
6. FATHER
A. NAME PAter.~ M~
B. COUNTRY OF BIRTH II 8 A
7. MOTHER
A. MAIDEN NAME Jo Anne Corso
B. COUNTRY OF BIRTH II S A
1
B. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES 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
YEAR
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
M~~~ Garei~URRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE MIiIIthP-IAa
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 118-54-1348
12. RESIDENCEA. ~rnrlc B. ~~
C. CHECK ONE D CITY D TOWN D~ILLAGE
~~CIFY Wappingers Falls
D. STREET ADDRESS 22 Clinton street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? [llfYES D NO
13. A. AGE 38 13.B. DATE OF BIRTH 04... /04a AOCA
~
14. EMPLOYMENT
A. USUAL OCCUPATION Food Service Worker
B. TYPE OF INDUSTRY OR BUSINESS Cullnart
15. PLACE OF BIRTH ~'" New YDrk
16. FATHER (I . A C Uf\lTRY NOT USA)
A. NAME .I~ph ('..rei"
B. COUNTRY OF BIRTH PUArto RIM
17. MOTHER
A. MAIDEN NAME Joan Kelley
B. COUNTRY OF BIRTH I J S A
2
lB. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
B. HOW DID LAST MARRIAGE END? (3) D ~VORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 11 / 19 / ~p7
MONTH DA Y R
D. ARE ANY FORMER SPOUSE(S) ALIVE? D ~S D 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
11/1911997 \Nhlte PlaiN, tJevi YorIc
1
DEATH
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D 1ST
D 2ND
D 3RD
D 4TH
d be ief that the information I provided is true
D DO;
D D
D D
D D
legal impediment exists
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK.
This license authorizes the marriage in New YDrk Stat of the bride and groom named above by any person authorized
Relations Law 911 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D 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
21. SIGNATURE OF GROOM.
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{ SEAL }
"-.,-I
NAME (PRINT)
DATE 09J05I2003
by New York Domesti(
TIME
MONTH
YEAR
DATE
AM
03:03'M
09
ZIP
ITY WN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
STATE
27. TYPE OF CEREMONY
o D RELIGIOUS
9 D OTHER, SPECIFY
1 C3"'C1vil
A. STATE NEW YORK B. COUNTYG-/ilJ<bY-t
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF rB""TOWN OF D VILLAGE OF
SPECIFY ell fU iJ
I~ '7
TITLE U"VV/V .:::r"'v!:' "Ticl!. -II? ~Ji-f,
DATE i I) - 4-0 '"3
/V.. 7",.. I :l. J J CJ
I STATE
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
:c.O ~ /0 ...
29. OFFICIANT I'f'" A-> I... 1M D L.
NAME (PRINT) ... . VVtT V /V'~ ru V L A.
f ,/J I.
SIGNATURE. W ~ O~
MAILING ADDRESS / . .
7 ,0/1 V/.I!.. e.r; ~./i viR VJ(,/"~
STREET CITYITOWN
30. WITNESS TO CEREMONY
NAME (PRINT) r"fT(z(t.. MA-YTH Ev>
SIGNATURE. llfJlrA 1'J1;y~
DOH.9B (11/98)
0]
28. PLACE WHERE MARRIAGE OCCURRED
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) -...k:xA n () e...
SIGNATURE.
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