054
J COUNTY Dutchess
CITYfTOWN Wappinger
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1. A. FULL NAME
STATE OF NEW YUH~ (THIS SPACEFOR STATE USE ONLY)
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE L 0 SUPPLEMENTAL FILE
FROM THE GROOM FROM THE BRIDE
,:!~!~Id W. J. ~~'~!~SURNAME 11. A. FULLNAME FIRST K~~!t~ Marie M~'1~SURNAME
-1
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Giglio
(OPTIONAL. SEE REVERSE) 1"4-66-8654
D. SOCIAL SECURITY NUMBER - ~------
12. RESIDENCEA. New York B. Oldchess
(~) (C~TYI
c. CHECK ONE 0 CITY 0 "/bwN 0 VILLAGE
~~CIFY WapDinaer
D. STREET ADDRESS 3 B Wildwood Drive ZIP
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE 'Ii 13.B. DATE OF BIRTH ----mJ~ / !lJ
14. EMPLOYMENT
A. USUAL OCCUPATION Un - Emplqyed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Sharon_ l.onneclir.lJt
(CITY. STATE'iOOUNTRY IF NOT USA)
16. FATHER
A. NAME Geor:ge Mn.ptly
B. COUNTRY OF BIRTH (J S A
17. MOTHER
A. MAIDEN NAME Palncia Goodrow
B. COUNTRY OF BIRTH II S .6.
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
(2) 0 DEATH
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 098-60-8413
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B Dutchess
(STATE) J '(COUNTY)
C. CHECK ONE 0 CITY D-rOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 3 B Wildwood Drive
12590
12590
YES 0 ~O
/ 'ltl1
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES D"'NO
3. A. AGE 34 3B. DATE OF BIRTH 10/ 1Q / 1Q6
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Downey Auto Repair
5. PLACE OF BIRTH New Rochelle~ New York
(CITY, STATElCOUNTRY IF NOT USA)
6. FATHER
A. NAME Harold Gialio
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME KathlP.f!n ~RlIR9hp.r
B. COUNTRY OF BIRTH Ireland
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
n
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
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
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
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
1ST
2ND
3RD
4TH
at the information I provided is true and that I de
.
21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York St person authorized by New
Relations Law ~11 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used onl for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Glori
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ .' . ,
'-t-' MAIL~8 U~dfebush Rd 09:1 tM 05 06 200 07
~8 w ~
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
04 2003
YEAR
1~CIVIL
2B. PLACE WHERE MARRIAGE OCCURR~ . I {
A. STATE NEW YORK B. COUNT~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VilLAGE OF
SPECIFY ( . \. ) Cl...ft; ~e. r
~
ZI
31. WITNESS T~O CREMO~NY -.J)
NAME (PRINT) ~-.-:k_. "
SIGNATURE~ ~~