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COUNTY Dutchess
CITYfTOWN VVarmintJer
~~J:~W 1368
~5~~J~R 3D
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Martin R. Con,a. JR.
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Samantha L. Bellantoni
MIDDLE CURRENT SURNAME
1. A FUll NAME
11. A. FULL NAME
ARST
FIRST
0.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Corsa
(OPTIONAL - SEE REVERSE) 0 ~ 5-58-7') 52
D. SDCIAL SECURITY NUMBER 0 .J
12. RESIDENCE A New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 "fOWN 0 VILLAGE
~~CIFY Beacon
D. STREET ADDRESS ~..? South Walnut Street ZIP '12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 "No
'12 / 27 /'1965
MONTH DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 0 3
D. SOCIAL SECURITY NUMBER 063-70-4 5
2. RESIDENCE A. ~tW) York B. (f!Jt~)hess
c. CHECK ONE 0 CITY 0 TOWN O""'ILlLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 95 Carmine Drive ZlP'f 2590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 ~ES 0 NO
3. A. AGE ':\2 3B. DATE OF BIRTH M / 1 Ii / 197
MONTH DAY YEAR
13. A. AGE
37
13.B. DATE OF BIRTH
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Housekeeper
B. TYPE OF INDUSTRY OR BUSINESS Hampton inn
15. PLACE OF BIRTH Tarrevtown. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Juan Antonio Mastrantuono
B. COUNTRY OF BIRTH South A.meriea
17. MOTHER
A. USUAL OCCUPATION Auto Technician
B. TYPE OF INDUSTRY OR BUSINESS Hudson Valley Volvo
5. PLACE OF BIRTH Peek<i!ltill,.j\Iew YorK
(CITY, STA'i'EMOU'UHY IF NOT USA)
6. FATHER
A. NAME Martin R Corsa Sr
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME Ger:tNde Oet:ller
B. COUNTRY OF BIRTH II ~ A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
A. MAIDEN NAME nnnnR r:nnnnr~
B. COUNTRY OF BIRTH USA
1
18., NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
(] 0
DEATH
o
DEATH
(]
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 FORMERSPOUSE(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
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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that
as to my right to enter into the marri
21. SIGNATURE OF GROOM ~
o
o
o
o
o
o
o
o
o
o
o
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York St bride and groom named above by any person authorized by New York Domestic
Relations Law ~t 1 to perform marriage ceremonies withi ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY,
o If checked, this license is. to be used only for the pur ose of a second or subse uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-v-I
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
NAME (PRINT)
SIGNATURE ~-
MAILING ADD':lESS
MONTH
DAY
YEAR
MONTH
DAY
YEAR
TIME
Zl
AM
12:1~
20 3 05
26 2003
03
23
A
27. TYPE OF CEREMONY
o,;R1.. RELIGIOUS
9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYDu; c.Le0
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ OF 0 TOWN OF 0 VILLAGE OF
SPECIFY 8-e 11 C () )1
03
TITLE Iff') rl In.. f...Jf..l ~ fv,l~ 5
DATE fJ 1~ .:L " Z 00..3
,
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) S 0( II Y'
S
SIGNI}TURE ~