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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ct1rHd~ (.I .1.diaflO
MIDDLE CURRENT SURNAME
COUNT'I' Outc:bes>
CITYrrOWN Wappinger
~ DISTRICT
NUMBER 1368
~5~~l~R 108
1. A. FUll NAME
FIRST
Q.
N
e, BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) "1Vi.ZA_'Z'A A "
D. SOCIAL SECURITY NUMBER .. ~ --=---..
2. RESIDENCEA.___)Ycxk B. ~
C. CHECK ONE 0 CITY 0 TOWN [l,IVILLAGE
~~~CIFY Wappingp.nr. !:Alkl
D. STREET ADDRESS '}j78 WMt MAIn strfl8t
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE?
3. A. AGE 28 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION SIdes. Fy~Jtive
B. TYPE OF INDUSTRY OR BUSINESS BottIni Fuel
5. PLACE OF BIRTH
6. FATHER
A. NAME Robed JaIepb Julia'lO
B. COUNTRY OF BIRTH II S A
7. MOTHER
ZIP 12590
~ES 0 NO
M
(I ,
A)
A. MAIDEN NAME DlryI ARne Huls8lr
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
DEATH
o
(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
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
o
o
o
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Annemarie Romano
MIDDLE CURRENT SURNAME
11. A. FUll NAME
FIRST
e. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Jurl8no
(OPTIONAL. SEE REVERSE) DD6
D. SOCIAL SECURITY NUMBER 052.54- 5
12. RESIDENCE A. NmEYork B. 9c:~
C. CHECK ONE 0 CITY 0 TOWN D~ILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 2778 West Mlln street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? elVES 0 NO
DQ /23 /\973
MONTH DAY YEAR
13. A. AGE 29
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Pawling Cent. Soh. Dlst.
15. PLACE OF BIRTH ~~e'b New York
(CITY, TE/COUN Y IF N T USA)
16. FATHER
A. NAME Allin JnRP.Ph Romano
B. COUNTRY OF BIRTH USA
17. MOTHER
13.B. DATE OF BIRTH
A. MAIDEN NAME M8dlvl) AngelA [JA ~LNO
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
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
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
o 0
impediment eXists
23. ~~~..g~~~Dorfc,~~OOR ciIfvB~Ef:~E.
This license authorizes the marriage in New York State
Relations Law ~11 to perform marriage ceremonies within
o If checked. this license is to
24. TOWN OR CITY CLERK
DATE 08/11/2003
f the bride and groom named above by any person authorized by New York Domestic
York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
used on for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
t'-"-.
{ SEAL }
'-v-'
NAME (PRINT)
SIGNATURE ~-
MAILING ADDRESS
TIME
MONTH
YEAR
IP
08:54M
PM
08
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
AT
27. TYPE OF CEREMONY
o 0 RELIGIOUS 1 0 CIVIL
9Sl OTHER, SPECIFY€Curne,V\\ c:n...\
03
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY D()tck~Sj
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF r;K TOWN OF 0 VILLAGE OF
SPECIFY AW\ev'\'"a
TITLECCu'n'\(,,"'l~r cm.^~~
DATE ft/8 110.:3.
Y I ~S ') ':l.
STATE ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~
DOH.98 (11/98)
NAME (PRINT)
SIGNATURE ~