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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jeffrey F P'l'5itsi
MIDDLE CURRENT SURNAME
COUNTY n, Itchess
CITYfTOWN WarringAr
~~J:~CRT 1'iFlR
~~~I~J~R 1 ~
1. A. FULL NAME
FIRST
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 077 -60-1506
2. RESIDENCEA. N XTATEI B. q~rss:
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~~CIFY f:::lsf Fishkill
D. STREET ADDRESS 7?:i Rp,p,kman Roan I t ~~ ZIP 1 ?~:i:i
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlLAGE? DYES olJ NO
M~:1i / ~j / ~71
3. A. AGE31
4. EMPLOYMENT
A. USUAL OCCUPATION Hea"y Equipment Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Dlltchess: QLlarry
5. PLACE OF BIRTH T ~ff.~~mlN~~o.yJ?~k
6. FATHER
3B. DATE OF BIRTH
A. NAME Friink L. PUiitiii
B. COUNTRY OF BIRTH I I S 4,
7. MOTHER
A. MAIDEN NAME Dona Malone
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
o
o
o
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
lis-a M PE'sr.o
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. s~~~~o~~~~~t~~o~~s~'ISitai
D. SOCIAL SECURITY NUMBER 093-58-5?48
12. RESIDENCE A.N 'fsTATE) B. ~~ss
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~~CIFYl=:::I~t Fi~hkill
D. STREET ADDRESS 7?:i Rep,km~n Ro~rl \ t ffi ZIP 1 ?~33
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
M~JrH /O~Y -1~L.~
13. A. AGE27
14. EMPLOYMENT
A. USUAL OCCUPATION Therapist
B. TYPE OF INDUSTRY OR BUSINESS Arlington r"trl
15. PLACE OF BIRTH ~~-RJ.1~.k!:'b~TR\' f(~1fr USA)
16. FATHER
13.B. DATE OF BIRTH
Sr.hl ni.:::t
A. NAMEVincent Pesco
B. COUNTRY OF BIRTHl I S A
17. MOTHER
A. MAIDEN NAME Grace Venticinque
B. COUNTRY OF BIRTH! I S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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 to
as to my right to enter into the marri e t
21. SIGNATURE OF GROOM ~
D D 1ST
D 0 2ND
D D 3RD
D D 4TH
st of my knowledge and belief that the information I provided is true and that I declare that no
D D
D D
D D
D D
gal impediment exists
23. SUBSCRIBED AND SWORN TO BEFOR M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of he bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State, THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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DATE 02/18/2003
by New York Domestic
TIME
MONTH
" YEAR
MONTH
YEAR
AM
PM 02
19
2003 04
19 2003
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AN~PECIFY)
D CITY OF ~OWN OF D VILLAGE CT"
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SPECIF, >~~. '11' _'__ $ --.- -= - ~
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ZIP
MITN~
NAME (PRINT
SIGNATURE