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Dutchess
COUNTY
Wappmger
CITYrro~~
DISTRICll.:J6B
NUMBER
REGISTER'lo I
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert C" Tucciariello
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
.atJ;
ftJ . f/~
L 0 SUPPLEMENTAL FILE
FROM ~~k~i~.I~~olar
~
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
1. A. FULL NAME
MIDDLE
CURRENT SURNAME
FIRST
B BIRTH NAME (MAIDEN NAME), u;.DIFFERENT II
I UCCI8ne 0
c. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)14 1-/.2-"1427
o SOCIAL S~~RITY NU~BEI\-
New 't orK uutcness
12. RESIDENCE A. B.
(STATE) ... (COUNTY)
C. CHECK 0Mi. D..,&:ITY 0 TOWN 0 VILLAGE
AND vvappmyers
SPECIFY 2 N~nlh Gj\'hOle Douievard
D. STREET ADDRESS Zj!lI
E. IS RE~6NCE WITHIN LIMITS OF CITY OR INCORPORATE~1LAGE~ 1 0
13. A. AGE 13.B. DATE OF BIRTH -
MONTH DAY
14. EMPLOYMENT R ~ "' M t
eLal anagemen
A. USUAL OCCUPATION Limittjll T Y!!V
B. TYPE OF IND~lW&~&rd'N~~vv Jt:'Ilit:y
15. PLACE OF BIRTH '
(CITY, STATElCOUNTRY IF NOT USA)
16. FATHER N" k" Sh \
A N ME Ie Ie 0 ar
. A lJSA
B. COUNTRY OF BIRTH - - . .
Y~~O
YEAR
11.
N
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)134-64-3378
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B Dutchess
(STATE) ., (COUNTY)
C. CHECK ON WE 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY appmgers
2. North Gnmore Boulevard 12590
D STREET ADDRESS z~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3 A AGE22 3B. DATE OF BIRTH 10 /24 / 979
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Warehouse Loader
B. TYPE OF IND4S.TRY OR B~~INES\l..,Ommumty Play I hlngs
5. PLACE OF BIRTHbmnx, New 'orK
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Robert Tucciariello
B. COUNTRY OF BIRTH U ~ A
7. MOTHER
A MAIDEN NAME Louisa Presta
B. COUNTRY OF BIRTH U S A
'I
B. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~CE CIVIL A1iULMENT
(2) 0 DEATH
12~90
17, MOTHER Th ,... t- I . -
.eresa ~.JIug Ie mint
A. MAIDEN NAME U :;, A
B. COUNTRY OF BIRTH 1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI'(fRCE CIVIL A~LMENT
DE(JTH
DEfiTH
B. HOW DID LAST MARRIAGE END? (31 0 DIVORCE (3) 0 ANNULMENT
C, DATE LAST MARRIAGE ENDED? / /
(21 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH 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
MONTH DAY YEAR
0, 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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
a:
LU
CD
::;
:J
Z
o
z
<(
f-
LU
LU
a:
f-
(fJ
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the m . e sat?! . .... ' ,
21. SIGNATLlRE OF GROOM ~ L.' 22. SIGNATURE OF BRIDE ~ \. "'i..... '\.. ".... ~. '--~~ C'\..'~
23. SUBSCRIBED AND SWORN TO BEFORE ME USE CURRENT NAME 09/21/2002
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within 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 CI1XpLEFlK 25, A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) I.;jl~na
{ 09/27/2002 TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ DATE
I..- -.J M~O'1\1fi ' NY 12590 O~ 26 09 28 200 11 26 2002
-v- ~: ~~
w
CJ)
Z
W
(.)
::i
YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT TH AND
PLACE INDI
ZIP
1~L
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B CO~
C. LOCATION OF CEREMONY
(CHECK ONE AN~ECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY ffA-H _Ii2ttHLL
NAME (PRINT) ·
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) ;J::: - ,,!.a. S
SIGNATLlRE ~ -~~ --
m.'~IL~ alt'-I? ()
~J-U"_ f'?--J'-~
SIGNATURE ~
DOH-98 (11/98)