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COUNTY 1)lttdI-~
CITYITOWN \l\lApplF\gM'
~~J~~~T 1~
~G~I~J~R 118
~ I A II: VI"" NI:VV YUHK.
DEPARTMENT OF HEALTH
AFRDAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GF,tOOM ,.
MichMI A SchIavone
MIDDLE CURRENT SURNAME
....1,...... II........"'........."
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Marisa M. Mocarski
1. A. FUll NAME
11. A. FULL NAME
MIDDLE
CURRENT SURNAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) ftlfU~ ~ ~J:DD
D. SOCIAL SECURITY NUMBER ~
2. RESIDENCE A. N V B. nutm818
(t-rATE) ~)
C. CHECK ONE 0 CITY lit TOWN 0 VILLAGE
~~~CIFY East Fishlcill
D. STREET ADDRESS 130 Woodcre5t DrIve ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
12 /03 /1977
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Sctiavone
(OPTIONAL - SEE REVERSE) 104-58-8316
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. NY B. Dutch818
(STATE).J (COUNTY)
C. CHECK ONE rdr CITY cr TOWN 0 VILLAGE
;~CIFY War::iong8f
D. STREET ADDRESS Mine DrIVe
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 28 13.B. DATE OF BIRTH 05
3: A. AGE ~
MONTH
3B. DATE OF BIRTH
4. EMPLOYMENT i
A. USUAL OCCUPATION Banker
B. TYPE OF INDUSTRY OR BUSINESS J. P. Moraen Ch8se
5. PLACE OF BIRTH Branx.. NM York
(CITY, STATEJCOUNTRY IF NOT USA)
6. FATHER
A. NAME Michael Albert SchIavone
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Karen Carmela Waeg
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Clerk
B. TYPE OF INDU~~': ~~.~~E~.~' 6. POII81 tieNfce
15. PLACE OF BIRTH t'~. NeW' York
(CITY, STATE/COUNTRY IF NOT USA)
16_ FATHER
A. NAME Vincent John MocalSld. Jr.
B. COUNTRY OF BIRTH U 6 A
17. MOTHER
A. MAIDEN NAME Rosemarie Carmela Cicio
B. COUNTRY OF BIRTH USA
,
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVBRCE CIVIL AN~LMENT
DEtJH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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) SELF SPOUSE
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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that 0 t
as to my right to enter into the marriag
21. SIGNATURE OF GROOM"
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
ge and belief that the information I provided is true and t
o 0
o 0
o 0
o 0
hat n~ legal impediment exists
09104I2OO3
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State f the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within 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.
{ ~ } ::~~;:I~=R CITY CLER)< J~' 25. A. SOLEMNIZATION PERIOD BEGINS
SEAL SIGNATU;;; ~ . . .t".Ie.1 DATE TIME MONTH
'-v-I MAI~ _. I d, ppinger Falls. NY 12590 12:31~~ 09
STREET CITYfT WN TATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED Z7. TV OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND AM
PLACE INDICATED. 3'.) 0 PM 9 0 OTHER, SPECIFY
---
YEAR
DATE
by New York Domestic
28. PLACE WHERE MARRIAGE ~URRED 1
Ut//f/" e JJ
A. STATE NEW YORK B. COUNTY
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C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0
SPECIFYf,..( ) k, ))
V/-7 OF