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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~~ r..amJJr.ho
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
COUNTY o.~..
CITYrrOWN Wappll\fr'r
~~~~T 1368
~5~~J~R 105
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Renee A. Vetrano
MIDDLE CURRENT SURNAME
1. A FULL NAME
11. A. FULL NAME
FIRST
0..
;::;
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) DBII'I'-';::D_~ft"'7
D. SOCIAL SECURITY NUMBER --i:II!!~
2. RESIDENCEA~)York B. ~
C. CHECK ONE D CITY ~OWN D VILLAGE
AND .AI-.
SPECIFY v_ppirtgP-l'
D. STREET ADDRESS 718 ChW-M Cay
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 31 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION r..alJl8fder
B. TYPE OF INDUSTRY OR BUSINESS ,nr.AI 11
5. PLACEOFBIRTH~Y~SA)
6. FATHER
I- A. NAME Gu-tauO C',am.mn
~ B. COUNTRY OF BIRTH Puerto Rico
Q 7. MOTHER
u::: A. MAIDEN NAME
u..
<C
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Camacho
(OPTIONAL. SEE REVERSE) 111 eD-5965
D. SOCIAL SECURITY NUMBER _ _-uu-
12. RESIDENCE A. NAwYork B. Dutchess
~E) (COUNTY)
C. CHECK ONE D CITY ~OWN D VILLAGE
AND Wa.
SPECIFY, ppnger :
D. STREET ADDRESS 716 CheIsee Cay ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES r::I NO
13. A. AGE ~ 13.B. DATE OF BIRTH DQ /30 /1970
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Sales Associate
B. TYPE OF INDUSTRY OR BUSINESS Zales Jewelers
15. PLACE OF BIRTH YonkBrs. New York
(CITY, STATEICOUNTRY IF NOT USA)
16. FATHER
A. NAME NchoI_ Vetrano Jr.
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Sandre ~
B. COUNTRY OF BIRTH USA
1
/
ZIP 12590
DYES r:!I NO
t::
Ruth RIver.
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID lAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
MONTH DAY YEAR
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
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1ST
2ND
3RD
4TH
I, being duly swom, epose and say,
as to my right to enter into the marri
D
D
D
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DATE
person authorized by New York Domestic
ose of a second or subse uent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
AM
01:11M
08
~
{ SEAL }
'-v-'
TIME
MONTH
YEAR
12590
S E
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
A
27. TYj:.F OF CEREMONY
o ~RELlGIOUS
9 D OTHER, SPECIFY
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~
C. LOCATION OF CEREMONY - -- -r
(CHECK ONE AND SPECIFY)
~TY OF D TOWN OF D VILLAGE OF
,(J{QQ n 1)1