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~~~I~J~' 25
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert Falcone
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
q'~'of
ael~t
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Tonya R. Colonna
MIDDLE CURRENT SURNAME
~
11. A FULL NAME
FIRST
1. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGcGolonna
(OPTIONAL - SEE REVERSIii 13-72 7055
D. SOCIAL SECURITY NUMBER I -
12. RESIDENCE New York EDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY'II'o TOWN 0 VILLAGE
AND 0 hk .
SPECIF\'Oug eepsle
o STREETADDRE~710 South Road G-1
ZI~ 260 1
o YEtO NO
1973
YEAR
BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVER::tV'71 66-0524
D SOCIAL SECURITY NUMBER U I -
2 RESIDENCE New York BDutchess
(STATE) J (COUNTY)
C CHECK ONE 0 CITY" 0 TOWN 0 VILLAGE
AND 0 hk .
SPECIFT" _ oug eepsle
o STREET ADDRESl71 0 South Road G-1
ZIP12601
o YE'fO NO
A981
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AG~9 13.8 DATE OF BIRTH 07 26
MONTH DAY
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A AG21 3B. DATE OF BIRTH 07 A3
MONTH DAY
14, EMPLOYMENT
A, USUAL OCCUPATIO"dministrator
8 TYPE OF INDUSTRY OR BUSINESColdwell Banker
15 PLACE OF BIRTSeacon New York
. (CITY, STAtEiCOUNTRY IF NOT USA)
16, FATHER
A. NAMPeter Colonna
8 COUNTRY OF BIR,\} S A
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4. EMPLOYMENT
A. USUAL OCCUPATlort"iaz - Mat Tech.
B. TYPE OF INDUSTRY OR BUSINESH. M. H. T. T. C.
5. PLACE OF BIR-rManhattan New York
(CITY, STATEICOtNTRY IF NOT USA)
6. FATHER
A. NAMERobert Falcone
B COUNTRY OF BIRTU S A
7. MOTHER
A. MAIDEN NAME C:Rthp.rinp. Prinr
B. COUNTRY OF BIRTJJ S A
8_ NUMBER OF THIS MARRIAGE1
9_ PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
17. MOTHER
A. MAIDEN NAMiMRryRnn Fp.lter
8 COUNTRY OF BIR,u S A
lB. NUMBER OF THIS MARRIAGE 1
19_ PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
al impediment exists
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1ST
2ND
3RD
4TH
I, being duly SWDrn, depose and say, that
as to my right to enter into th . sate.
21. SIGNATURE OF GROOM
o
o
o
o
o
o
ATURE OF BRIDE ~
ME
23. ~~ri,fTRJ~~DO~N-?O~.'~O~~ ZI~Bg~~~~E DATE08/08/2002
This license authorizes the marriage in New York St person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY,
o II checked, this license is to be used only lor the purpose 01 a second or subsequent ceremony.
~ 24 TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)Gloria
TIME
SEAL SIGNATURE ~
~ ~Me~R 2m:
STREET ZIP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
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YEAR
1~IL
28. PLACE WHERE MARRIAGE OCC~
A. STATE NEW YORK B COU ~
29. OFFICIANT
NAME (PRINT)