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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.John M Rolio
MIDDLE CURRENT SURNAME
23. SUBSCRIBED AND SWORN TO BEFORE E
SIGNATURE OF TOWN OR CITY CLERK II"
This license authorizes the marriage in New York ate of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies wit' New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl for the urpose of a second or subse uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
::I
COUNTY Dutchess
CITYITOWN Wappingt'!r
~~J:~~T 1 ".fiR
~B~~J~R 7~
1. A FULL NAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER nRA_RL:\n7~
2. RESIDENCE A ~W!/ ork B. -.g~dtwr~~~
C. CHECK ONE 0 CITY ohOWN 0 VILLAGE
AND
SPECIFY Hylip. Psrk'
D. STREET ADDRESS 71 r:ohp.V T p.rrR~p. ZIP 17.,01
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES cY NO
3. A. AGE ~a 3B. DATE OF BIRTH M~ / lAf. / y!R64
4. EMPLOYMENT
A. USUAL OCCUPATION Flp.~.ri~il'ln
B. TYPE OF INDUSTRY OR BUSINESS I B E W Local I If';liot:l ~63
5. PLACE OF BIRTH_Pc~~~ Yolt
6. FATHER
A. NAME John Bodo
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Dar:fa Sue Efts
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
DEATH
ODD
B. HOW DID ~ 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
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
OATE OF OECREE . PLACE ISSUEO AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
~
{ SEAL }
'-..t-I
NAME (PRINT)
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ..
DOH-98 (11198)
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Trl'l~p.v (.:l,p.rml'lno t:l.p.rmaf'ln
1!iIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Bodo
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER. 1J7~RO- 5064
12. RESIDENCE A. N~*EY or; B. ry~$~
C. CHECK ONE 0 CITY D...rOWN 0 VILLAGE
AND
SPECIFY Hylip. Psrk
D. STREET ADDRESS 7~ Cohp.y T ~rrRcP ZIP 12601
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE 33 13.B. DATE OF BIRTH MOfM / !h
14. EMPLOYMENT
A. USUAL OCCUPATION T eacber
B. TYPE OF INDUSTRY OR BUSINESS Beacon C~ School District
15. PLACE OF BIRTH -Pc~_~~N. Yol=k
16. FATHER
A. NAME Emest Germano
B. COUNTRY OF BIRTH USA.
17. MOTHER
YES EY'NO
/.i~
A. MAIDEN NAME Theresa Melite
B. COUNTRY OF BIRTH U S .It
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
DEATH
g
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF OECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
legal impediment eXists
22. SIGNATURE OF BRIDE II"
TIME
MONTH
YEAR
MONTH
YEAR
03
22
200 05 20 2003
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY /)//rctt&$'J
C.
NAME (PRINT)
SIGNATURE II"