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Dutchess
COUNTY W -
applnger
CITY!TOW~68
DISTRICT~I ,;j
~~~I~~~R36
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM-THE GBOOM
RIchard Do Salvatore
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
1J117.(
-' - IJ if _ 71
!} 'XI /'1
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Danielle Po Scianna
~
A FULL NAME
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
"-
N
B BIRTH NAME (MAIDEN NAME), )E..DIF,F~RF;H
:.::>alValore
C. SURNAME AFTER MARRIAGE
(OPTIONAL ~ SEE REVERSE011-12-9591
o SOCIAL S~~RITY ~)1BEIl_
New YOrK uutcness
12 RESIDENCE A. (STATE) ~ B. (COUNTY)
C. CHECK QtlIf. 0 CITY 0. TQ~N 0 VILLAGE
AND vvappmgers J!"a.Us
SPECIFY 15 School Street "12590
~~m~~ ~
E IS R~~NCE WITHIN LIMITS OF CITY OR INCORPORATE~ dLLAGE? 0
13. A. AGE 13.6. DATE OF BIRTH ,,30
MONTH DAY
14 EMPLOYMENT .
. SOCial Welfare Worker
A. USUAL OCCUPATION 0' ~... c '"
UlClless oun'l
B. TYPE OF INDI,LSTRY CJB ,BUSINESS
15. PLACE OF BIRTHf"#ougnKeepsle, New YOrk
(CITY, ST ATEiCOUNTRY IF NOT USA)
16. FATHER J h S.
A 0 n Clanna
A. N ME USA
B. COUNTRY OF BIRTH
B BIRTH NAME. IF DIFFERENT
C s~~~~~N'?:'LTE~~t~~e~~SE~ 22-66-7667
o SOCIAL SEr;rewNl.~S'\ uutcness
2 RESIDENCE A. (STATE) ..,. B. (COUNTY)
C ~~6CK otJappth~erfio1.<t"ts 0 VILLAGE
SPECIFY 15 School Street 12590
o STREET ADDRESS Z$
E. IS R~~NCE WITHiN LIMITS OF CITY OR INCORPORATE~V6LAGE?)12 0 YES .H,.~~
3. A AGE 3B. DATE OF BIRTH - ~
MONTH DAY YEAR
Y'Jg9l0
YEAR
4. EMPLOYMENT C t
arpen er
A. USUAL OCCUPATION M fr AI ct II
an eu ons ruc on
B. TYPE OF IND\,IliTRY OR BU:ililIESS V do
ceacon New . 0.1\
5~ PLACE OF BIRTH '
(CITY, STATE/COUNTRY IF NOT USA)
6 FATHER
Angelo Salvatore
A. NAME USA
B. COUNTRY OF BIRTH
7 MOTHER
17. MOTHER DO 5t rito
A. MAIDEN NAME lane e I
B COUNTRY OF BIRTt!J S ~
18 NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D~ORCE CIVIL A~ULMENT
D{fH
Jeanne Van Allen
A. MAIDEN NAME
USA
B COUNTRY OF BIRTH 2
8. NUMBER OF THIS MARRIAGE
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~RCE CIVIL A~UlMENT
DftTH
-
ffi
CD
'"
:J
Z
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z
'"
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go
UJ
B HOW DID LAST MARRIAGE END? (3) 0 DIVO'ftl 13) , tfNULMEN~Ojj.p DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT 12) D DEATH
C DATE LAST MARRIAGE ENDED? ~~ / / C. DATE LAST MARRIAGE ENDED? / /
MON"" DAY YEAR MONTH D'A Y YEAR
o ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO 0 ARE ANY FORMER SPOUSEIS) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
1 ST 1'tf1f~~t)(jifbut~n~ssEt~unNF~ew"ork S~F SPO~E 1 ST (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) S~F SPO~E
2ND 0 0 2ND D D
3RD D D 3RD 0 0
4TH 0 0 4TH 0 0
~sbt~n~yd~~htS~O~~i~~~f~~h;n~a~~Y' ~ t~fe the best of my knowledge and belief that the InformatIOn I provided IS .::f{; t~at I ~eclare tha~g~ /,pe~lment eXists
21 SIGNATURE OF GROOM ~ 2 SIGNATURE OF BRIDE ~~U7.J.t2J!Ltl Y_ J4,(l.1 () j (j 10
23 SUBSCRIBED AND SWORN TO BEFORE ME USE CURRENT NAME 04/15/2002
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York Sta person authorized by New York Domestic
Relations Law S11 to perform marriage ceremonies within ew 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 <GY& K 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT>
w
C/)
Z
W
()
::i
~
{ SEAL }
'-v-'
TIME
MONTH
DAY
YEAR
MONTH
YEAR
04/15/2002
DATE
Y 12590
2:36
AM
PM
04
16
2002 06
14 2002
ZIP
1~
28 PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY ;;)11 JCtk.'-:j
C
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICC
29 OFFICIANT
NAME (PRINT)
~
SPECIFY
NAME (PRINT)
SIGNATURE ~ .
DOH-98 (11/9B)