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COUNT'Dutchess
CITY/TowrWappinger
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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
AleJn M nF? FI Jsr,n
FIRST MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
,~{,{
If~~1'~41
.-J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
np.nisF? M FF?nF?rir,n
FIRST MIDDLE CURRENT SURNAME
11. A. FULL NAME
B BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGEEp.rlprir,n
(OPTIONAL. SEE REVERSI;l,
o SOCIAL SECURITY NUMBER u66-54-3741
12. RESIDENCE N Y BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITYootJ TOWN 0 VILLAGE
AND \^' .
SPECIFWJLapplnger
o STREET ADDRE~ A Woodhill Green
Zl~ 2590
o YE~D NO
~J
YEAR
3. A. AG~9
O?
MONTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AG~F'J 13.8. DATE OF BIRTH (\9 /J9
MONTH DAY
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCuPATlorLegal Assistant
B. TYPE OF INDUSTRY OR BUSINESMaster Card Intn'l.
15. PLACE OF BIRTtI?ouahkeeosie. New York
(CIT~ STATE/COUNTRY IF NOT USA)
16. FATHER
A NAMBl'mcent Feder"ico
8. COUNTRY OF BIRrU S A
17. MOTHER
A MAIDEN NAMd nuise Aurgaz70li
8. COUNTRY OF BIRrU S A
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
4. EMPLOYMENT
A. USUAL OCCUPATIONContractor
B TYPE OF INDUSTRY OR BUSINESsSelf-emoloved
5. PLACE OF BIRTReekskilL New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A NAMESalvatore De Fusco
B. COUNTRY OF BIRT~taly
7. MOTHER
A. MAIDEN NAME Savina SF?rafino
B. COUNTRY OF BIRTH Italy
B. NUMBER OF THIS MARRIAGE1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE lAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE lAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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 DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0
2ND 0 0
3RD 0 0
~ 0 0
at the information I provided is tue am~~ n~gal impediment exists
22. SIGNATU~E OF BRIDE ~ ~CURRENT NAME
DATE 09/20/2002
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groDm named above by any person authorized
RelatiDns Law ~11 to perform marriage ceremDnies within New YDrk 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 C!.ERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT,G om~ J. Mar
{ ~
SEAL SIGNATU'f;
'-.;-I ~J~i~aretfush 0: 15 AM
STREET ZIP PM
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
by New York DDmestic
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY D'J'rc...l,IZ~>
1~Vll
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
C. lOCATION OF CEREMONY
(CHECK ONE AN~ECIFY)
o CITY OF ~TOWN OF 0 VilLAGE OF
,/ /. ~I 'C
SPECIFY i~ i 1:-' I 5 l j L
--- .
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TITL:TO "'U N:f\J :?t/vR:
( O!2G!6 ~
{2.S-3~
DATE
NAME (PRINT)
SIGNATURE ~
STATE ZIP
31. WITNESS TO CEREMONY
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SIGNATURE~..c1/:.~ =1 ~