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COUNTY Dutchess
CITyrrOWN Wappinger
~~~~kCRT 1368
~~~'~J~R 78
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Patrick E Dorey
MIDDLE CURRENT SURNAME
FIRST
MIDDLE
(THIS SPACE FOR STA TE USE ONL Y)
[,1j!1/t
J _/0.,1':/
/CJ 7 tl v J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Theresa di Pierno
~
A FULL NAME
11 A. FULL NAME
CURRENT SURNAME
FIRST
c..
N
8 BIRTH NAME. IF DIFFERENT
8 BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C SURNAME AFTER MARRIAGE Dorey
(OPTIONAL - SEE REVERSE) 133-62-4050
o SOCIAL SECURITY NUMBER
12 RESIDENCE A. N Y B. New York
(ST A T.~ (COUNTY)
C CHECK ONE IT CITY 0 TOWN 0 VILLAGE
~~~CIFY New York City
o STREET ADDRESS 7 Carmine Street Apt. 11
3 A AGE 34
ZIP 10014
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? dYES 0 NO
09 /02 /1967
YEAR
13 A. AGE 34
13.B. DATE OF BIRTH
3B. DATE OF BIRTH
MONTH
DAY
YEAR
4. EMPLOYMENT
A USUAL OCCUPATION Web Designer
B TYPE OF INDUSTRY OR BUSINESS Nickeloden
5. PLACE OF BIRTH Clearwater, Florida
(CITY. STATE COUNTRY IF NOT USA)
14 EMPLOYMENT
A. USUAL OCCUPATION Arts Administration
B TYPE OF INDUSTRY OR BUSINESS American MUSIC Center
15. PLACE OF BIRTH Bronx, New York
(CITY, STATE, COUNTRY IF NOT USA)
16 FATHER
A. NAME Gerald James Oi Pierno
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Lillian Rose Russell
B. COUNTRY OF BIRTH USA
lB NUMBER OF THIS MARRIAGE 1
19 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
6 FATHER
A. NAME Eugene oore~
B. COUNTRY OF BIRTH U S
7. MOTHER
A. MAIDEN NAME Marv Bonner
B. COUNTRY OF BIRTH USA
B NUMBER OF THIS MARRIAGE 1
9 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
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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
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
0 0 1ST 0 ~
0 0 2ND ~: 0
0 0 3RD C
IJ :-1
21 SIGNATURE OF GROOM ~
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 by New York Domestic
Relations Law 911 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 ~LEFJK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) G 0, n J M~rse
{"TIME MONTH YEAR MONTH
SEAL SIGNATURE ~. U~
'-v-I MAI~~ NfPClCftebush Rd, 08:59AM 06 11 200 GB 09 2002
STREET STATE 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
DATE
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY ON4V'A
C LOCATION OF CEREMONY (J
(CHECK ONE AND SPECIFY)
o CITY OF ~WJJOF VILLAGE O~F
~ ., trl.cnt..ef,
SPECIFY 1/ ltl-
"
29. OFFICIANT
NAME (PRINT)
ZIP
31. WITNESS TO CEREMONY -
""' ''''''I 11 ul~A 3cbe.L+,--,::", '" .-=
SIGNATURE ~ ~-,-cI',-- t~~
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