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COUNTY Dutchess
CITYITOWN Wappinger
~~~~~c~ 1368
~5~lgJ~R 132
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael P. Grosso
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
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L D SUPPLEMENTAL FILE
FROM THE BRIDE
Usa M. Chiappetta
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Grosso
(OPTIONAL. SEE REVERSE) 058 66 6863
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. N Y B. Dutchess
(ST A TEI..J (COUNTY)
C. CHECK ONE 0 CITY L.I TOWN D VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 23 D Alpine Drive
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 049 76 8793
D. SOCIAL SECURITY NUMBER --
2 RESIDENCE A. N Y B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r:5 TOWN 0 VILLAGE
~~~CIFY Wappinaer
D. STREET ADDRESS 23 D Alpine Drive
ZIP 12590
YES ~ NO
/1976
YEAR
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 33 3B. DATE OF BIRTH 11 /
MONTH
ZIP 12590
DYES t5 NO
18 / 196
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D
13. A. AGE 26 13.B. DATE OF BIRTH 01 /09
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS Home Depot
5. PLACE OF BIRTH Waterbury. Connecticut
(CITY, STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Customer Service
B. TYPE OF INDUSTRY OR BUSINESS Feehan Insurance Agncy.
15. PLACE OF BIRTH Port Chester, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Francis Chiappetta
B. COUNTRY OF BIRTH USA
17. MOTHER
6. FATHER
A. NAME Peter Grosso
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Maryann Siracki
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
o 0
A. MAIDEN NAME Concetta Graziano
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o O.
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES 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
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES 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 1ST
o 2ND
D 3RD
o 4TH
elief that the information I provided is true
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21.
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 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.
o If checked. this license is to be used only for the pur se of a second or- .subsequent- ceremony.. -
~ 24. TOWN OR CITY CLE~K 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) GlOri
{ ~ ~
SEAL SIGNATURE ~
'- -J MA~tflOfflrdf~bush Rd, 08:45AM 08
--v- ZIP PM
DATE
by New York Domestic
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YEAR
CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY
(CHECK ONE AND pCIFY)
o CITY OF ~WN OF D VILLAGE OF
SPECIFY WIJNlf); ~
,
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