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COUNTYDuichess
CITY/TOWN if\!appin~1er
~~J~~C:136B
~5~~J~R '113 9
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM TH E GROOM
Louis J. Visconti, JR.
MIDDLE CURRENT SURNAME
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
I
-M11l
1/~/3-t'!~
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Elizabeth Camp
MIDDLE CURRENT SURNAME
.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Visconti
(OPTIONAL' SEE REVERSEl071_72_9793
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANew York B. Dutchess
(STATE). (COUNTY)
C. CHECK ONE 0 CITY tj TOWN 0 VILLAGE
~~~CIFY Wappinger
o. STREET ADORESsl1 Alpert UrNe
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE>i '18 62 ~29tj.
D. SOCIAL SECURITY NUMBER ., fI!:. - -~ U
2. RESIDENCE A New York B. Dutchess
(STATE) wi... (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
D. :~:~;; A::~~;nXf;ert Drive
ZIP 1 L3l:fU
0;/'
YES 0 NO
;978
YEAR
3. A AGE37
11
1?:<1l:fO
ZIP 'J:..~
.".
YES 0 NO
/1964
YEAR
DAY
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
/25
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
AO
13.8. DATE OF BIRTH
08
13.A AGE24
38. DATE OF BIRTH
MONTH
DAY
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Self - Employed
B. TYPE OF INDUSTRY OR BUSINESS Visconti Lawn Care
5. PLACE OF BIRTH Bronx, New York
(CITY, STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Recepiionist
VI~~"'nh I Rwn I "Rft'!
B. TYPE OF INDUSTRY OR BUSINESS" .--......-. __..n_ '-'-- '"
15. PLACE OF BIRTH Poughkeepsie, New Y orl<
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Louis Visconti
8. COUNTRY OF BIRTH USA
16. FATHER
A. NAME Edward Camp
B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Geraldine Kierstead
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
7. MOTHER
A. MAIDEN NAME Renee Marcolina
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) [j DIVORCE (3) 0 ANNULMENT (~ 0 DEATH
C. DATE LAST MARRIAGE ENDED? 05 / -15 /20UO
MONTI;j,t 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 05/15/2000 Pouqhkeepsie, New York c5 0 1ST
2ND 0 2ND
3RD 0 3RD
4TH 0 4TH
I. being duly sworn, depose and say, that t elief that the infDrmation I provided is tru
as to my right to enter intD the marria e
(3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
YEAR
MONTH DAY
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
o 0
o 0
o 0
o 0
egal impediment exists
21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE
w
en
z
w
u
:J
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wi in New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLI=:RK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Glona. J. Morse
. TIME MONTH
SEAL SIGNATUR~ 0 DATE 10/18/2002
'-..-' M~'Mr8Me ush. NY 12590 02:38 ~~ 10
STREET STATE ZIP
I CERTIFY THAT I SOLEMNIZEO 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME MO DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER. SPECIFY
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
1 ~ CIVIL
A. STATE NEW YORK B COUNTYO(o..C'\~
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
cg J 'lPDl..
\"'21.00 \
ZIP
31. WITNESS =t-EREM?NY
NAME (PRINT) O-..s f
o CITY OF II TOWN OF 0 VILLAGE OF
SPECIFY N~ W \(\~cr