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COUNTY Dutchess
CITYITOWN Wapoinger
~~J~~~T 1368
~5~~J~R 21
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Steven Devizio
MIDDlE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
I, A, FULL NAME
FROM THE BRIDE
Arian Elizabeth Costa - Steinman
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Costa
C. SURNAME AFTER MARRIAGE Oevi7io
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 091-68- 7712
12. RESIDENCEA. N~1I!EYork B. ~ess
C. CHECK ONE 0 CITY 0 TOWN D'If(,ILLAGE
~~CIFY Wappingers Falls
D. STREET ADDRESS 8lJpper H~nry ~reet ZIP 1 '590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIULAGE? 0 YES [Y"NO
13. A. AGE 32 13.B. DATE OF BIRTH ~ / iR /1 ~JJ
14. EMPLOYMENT
A. USUAL OCCUPATION Domestic Engineer
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH PnlJnhkep.n~ip'_ Np.w Ynrk
(CITY, ii'rIiTEICOUN'i'RY IF MJT USA)
16. FATHER
A. NAME RichArd C":nstA
B. COUNTRY OF BIRTH I J ~ A
17. MOTHER
A. MAIDEN NAME Roberta lehr
B. COUNTRY OF BIRTH I I 5 A
16. NUMBER OF THIS MARRIAGE 7
11. A. FUll NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) "\
O. SOCIAL SECURITY NUMBER 1.~:5-58-fl4n1
2. RESIDEN~EA. ~~ York ' B. ~ess
C. CHECK ONE 0 CITY 0 TOWN [JI'VILLAGE
~~CIFY Wappingers Falls
D. STREET ADDRESS 8 Upper Henry Street ZIP 12590
E. IS RESIDENCE WITHIN UM/TS OF CITY OR INCORPORATED VIULAGE? 0 YES c!" NO
3. A. AGE 42 3B. DATE OF BIRTH ~ /~} / y~60
4. EMPLOYMENT
A. USUAL OCCUPATION District Manager
B. TYPE OF INDUSTRY OR BUSINESS n R PutRrYp.ting
5. PLACE OF BIRTH Rrnnv Np.w Y nrk
(CITY, STA'iEiCOiiiiRV IF NOT USA)
6. FATHER
A. NAME Richard nevizio
B. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A. MAIDEN NAME Victoria PeRllo
B. COUNTRY OF BIRTH I I 5 A
8. NUMBER OF THIS MARRIAGE ')
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 n n
B. HOW DID LAST MARRIAGE END? (3) oIDIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 02/ '14 / 7003
MONTH DAV mri
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~S 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE ' PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATEJCOUNTRY, IF NOT USA) SELF SPOUSE
1
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D~IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE.LAST MARRIAGE ENDED? .03/ 04 / 1009
MONTH Di{I1 ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? D""'s 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
g2!14!l003 PQyghRepsi~, N~w Yor:k
D"'"
o 1ST 03/04/1999 PQyghk'@@f1si@, N@w York 0 [)ol"
o ~D 0 0
o 3RD 0 0
o 4TH 0 0
be Ie t att e In ormation prOVided IS true and t at declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ ~ ~ -m- -.5;'-n., fLrrtn. 0
USE CURRENT NAME
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23. SUBSCRIBED AND SWO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York bride and groom named above by any person authorized
Relations Law ~11 to partonn 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 purpose of a second or subse uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE (t~IOS/?003
by New York Domestic
r-^-.
{ SEAL }
'-v-I
NAME (PRINT)
SIGNATURE ~ -
MAILING ADDRESS
MONTH
YEAR
TIME
MONTH
DAY
YEAR
10:2~~
200
06
05
04 2003
03
IP
A
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
l~IVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEWYORK B. COUNTY~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~VILLAGE OF
sm
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
SPECIFY
31. WITNESS TO
NAME (PRINT)
SIGNATURE~
DOH-96 (11/96)
NAME (PRINT)
SIGNATURE ~