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COUNTY Dutchess
CITYITOWN Wappinger
~~~~~CRT 1368
~G~I~J~R 114
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Steven M u/vanev
MIDDLE CUARENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
t:tkt
LJ -3'7 .t';1
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Donna M. Piacitelli
~
1 A FULL NAME
11 A FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
Cl.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Mulvaney
(OPTIONAL. SEE REVERSE) 100-64-3677
o SOCIAL SECURITY NUMBER
12 RESIDENCE A. N Y B. Dutchess
(STATE).J (COUNTY)
C. CHECK ONE 0 CITY LJ TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
o STREET ADDRESS 16 East Dogwood Drive ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES c:; NO
07 /24 /1970
BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRiAGE
(OPTIONAL. SEE REVERSE) 6?47
D SOCIAL SECURITY NUMBER 091-66-_
2 RESIDENCE A. N Y B. Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY !'1 TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
o STREET ADDRESS 16 East Dogwood Drive ZIP. 12601
E. is RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES t5 NO
3 A AGE :fi 3~ DATE O~ BIRTH 10 / 26 / 196
MONTH DAY YEAR
YEAR
13 A. AGE 32
13.B. DATE OF BIRTH
MONTH
DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS Bottini Fuel
5 PLACE OF BIRTH Port Jefferson, New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Edward P. Mulvaney
B. COUNTRY OF BIRTH USA
14. EMPLOYMENT
A USUAL OCCUPATION Investigator
B TYPE OF INDUSTRY OR BUSINESS Blue Cross/ Blue ShIeld
15 PLACE OF BIRTH Mount Kisco, New York
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME William John Pi a c'ltell i
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Phyllis Anne Iannuzzi
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
7 MOTHER
A. MAIDEN NAME Jeanette L Dimattia
B. COUNTRY OF BIRTH USA
8 NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
o
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B. HOW DID lAST MARRIAGE END? (3) c'1 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 10 / 11 / 2000
MONTV DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20.
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 10/11/2000 Ulster Co., New York 0 [f 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 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 tha
as to my right to enter into the ma~ri te. /. .
.. ~-Ua'..'t .
21. SIGNATURE OF GROOM~' 22. SIGNATURE OF BRI
SE ~
o 0
o 0
o 0
o 0
re that no legal impediment exists
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
MONTH OAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
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
YEAR
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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 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 purpose of a second or subsequent ceremony.
~ 24 TOWN OR CITY CLEflK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Glona J Mo se
{TIME MONTH YEAR
SEAL SIGNATURE ~
'-y-I MA~t)G~cfd ~Dush Rd, 01 :39~~ 07 27 200
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.
09
24 2002
DATE
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON
MONTH
DAY
YEAR
1)!( CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY (j)(~i'c-A~,
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
SPECIFY
SIGNATURE ~