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COUNTY Dutchess
CITy:rOWN Wappinger
~~~~~~ 1388
~[j~~J~R 104
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Frank' Miclu:lel [)j Febio
MIDDLE CURRENT SURNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
-.J
1. A. FULL NAME
11. A. FULL NAME
MI~nna Pica CURRENT SURNAME
FIRST
FIRST
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) ...........
D. SOCIAL SECURITY NUMBER l.,......-54-~1
2. RESIDENCE A. N Y B n. drh-cr.
(STATE) ~
C. CHECK ONE 0 CITY [)I'TOWN 0 VILLAGE
~~~CIFY Wappinger
o STREET ADDRESS 38 st. Nchol85 Road. AP- 21P
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGE ~~ 38. DATE OF BIRTH 1? / 1A
MOrJ'tll' tlA1
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Pica
C. SURNAME AFTER MARRIAGE ---Di a:=a~D
(OPTIONAL - SEE REVERSE,.-. r- ""
D. SOCIAL SECURITY NUMBER .c15&71~3199
12. RESIDENCE A N v B. n.~
i~ATE) I"'f~
C. CHECK ONE 0 CITY o;rOWN 0 VILLAGE
AND Wa .
SPECIFY ppnger
D. STREET ADDRESS 38. Sl Neild. Road. Apt. 2zIP 1~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
JIlH / 12y ~'91,l
125gQ
YES r!l' NO
/~
13. A. AGE 2&
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS HeRdrtck Hudlon Seta. DI!
15. PLACE OF BIRTH ~ul-1XMT USA)
16. FATHER
13.B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Engineer
B. TYPE OF INDUSTRY OR BUSINESS \N8verty Sound
5. PLACE OF BIRTH RochMt8r New York'
(CITY, STATElCOU1!rRY IF NOT USA)
6. FATHER
A NAME Frank Di Fabio
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME U.ry Marconi
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
A. NAME Thomas Vincent Pica
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Samara Marga.. HeRlek
8. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
(2) 0 DEATH
1
o 0
B. HOW DID LAST MARRIAGE END? (3) cYblVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 12 / na / ?M?
MONTH ~ ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? []II(ES 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
12J0912OO2 Dutchess Co., N Y
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 0
o 0
o 0
o riI'
o 0
o 0
o 0
I pediment exists
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en
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(,,)
::::i
YEAR MONTH
YEAR
TIME
MONTH
10:54 AM
PM 08
2003 10 03 2003
05
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
ZIP
wsrctVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY\ J.. ~ ft-, ~f
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) "J:::a.s\ \ e 1 \Q.
SIGNATURE. r-:DO-...Ai'~ 1 \. \
Ur\..{
~~