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COUNTyDutchess
CITY-TOWN Wappinaer
, ~~~:~~T1368
~5~'~J~R15 7
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Albert J. Rizzo
MIDDLE CURRENT SURNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
" j} 1Jt
rVV 1--
11 I
/ . ,1 '1 - (,l
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Karen A Hileman
MIDDLE CURRENT SURNAME
--.J
A FULL NAME
11. A FULL NAME
FIRST
FIRST
0-
N
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
{OPTIONAL - SEE REVERSE,l, 22 ., A A565
o SOCIAL SECURITY NUMBER I -~
2 RESIDENCE ANew York B. Dutchess
C CHECK ONE (STAg) CITy4{] TOWN 0 VILLAGE (COUNTY)
AND W .
SPECIFY applnger
o STREET AODRESS 16 Marlorville Road ZIP 12590
E is RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YESo{] NO
3. A AGF5fl 3B DATE OF BIRTH 08 /10 /1945
MONTH DAY YEAR
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Rizzo
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 112-44-9923
12. RESIDENCE ANew York BDutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
O. STREET ADDREss16-18 ~.1arloI"Jille Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'!"J NO
13 A. AGF38 13.B. DATE OF BIRTH ---Q~TH -1lAy t9~R
14 EMPLOYMENT
A. USUAL OCCUPATlONProduction Accociate
B. TYPE OF INDUSTRY OR BUSINESSCoca f~ola
15 PLACE OF BIRTrC~J~~ti~~fJT~~~Xg~
16. FATHER
A NAMeRobert Hileman
B. COUNTRY OF BIRTU ~ A
17. MOTHER
A. MAIDEN NAME Winnie Mericle
B. COUNTRY OF BIRTtll ~ A
18 NUMBER OF THIS MARRIAGE '}
4. EMPLOYMENT
A. USUAL OCCUPATION Production Associate
B TYPE OF INDUSTRY OR BUSINESSCoca Cola
5. PLACE OF BIRTt-Oueens New York
(CITY, STAT~JCOUNTRY IF NOT USA)
6 FATHER
A. NAME Albert Rizzo
B. COUNTRY OF BIRTHU S A
7 MOTHER
A. MAIDEN NAME Nicoletta C8p1do
B COUNTRY OF BIRTH LJ S A
8 NUMBER OF THIS MARRIAGE3
9 PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT DEATH
1 0 1 1 0 0
B HOW DID LAST MARRIAGE END? {3rD DIVORCE {3} 0 ANNULMENT {2} 0 DEATH B. HOW DID LAST MARRIAGE END? (3)ti DIVORCE (3) 0 ANNULMENT (21 D DEATH
C DATE LAST MARRIAGE ENDED? 05 / ,}7 /1999 C DATE LAST MARRIAGE ENDED? 07 / OR /1996
MONT~ DAY YEAR MONTIj, DAY YEAR
o ARE ANY FORMER SPOUSE(S) ALIVE? "D YES 0 NO 0 ARE ANY FORMER SPOUSE(S) ALIVE? !J 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
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1STO::\/7::\{19fiR Qllp.en~ N~w York 0 0 1sTOI108!1996 fi~hkill, New York r!f
2ND05/27/1999 Nassau 'County tj 0 2ND 0
3RD 0 0 3RD 0
4TH 0 0 4TH
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true an
as to my right to enter into the marriage S te.
21 SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
23 ~~NSfT~~~DO~NT~~~O~RN~~yBg~~~~E DATE 12/28/2001
This license authorizes the marriage in New York S of the bride and groom named above by any person authorized by New York Domestic
Relations Law 911 to perform marriage ceremonies with' 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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Gloria J Morse
{ .../.J /] TIME MONTH DAY YEAR MONTH
SEAL SIGNATURE ~ --~~ // ~~ ",DATE12/:7R/2001
MAILING ADDRESS ~.. .~ 9:39 AM
'-v-I 20 Middfebush Rd, inopJ Faffs, NY 12590 PM 12 29 2001 02 26 2002
STREET C~WN STATE 21P
~~~R~~~Ri~~; IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO DAY YEAR 0 0 RELIGIOUS 1 ~CIVIL
~t1~E ~~gICAJT~~E TIME AND O~ '2. { 9 0 OTHER, SPECIFY
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTYPJTelh;;SS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
TITL~ER;riIMr:lr;r'(a3 #lJir
DATE \J&-Al ::21, 7.m'L
MAlLIN .A 0 / / .,c ~ I / ~ "1"7
GSEfC,C/c>(~ 'L., U//17:P//I.I~r7T~ 'L{/_ J.:;;.J,,;?'O
CITY/TOWN
kh
29. OFFICIANT
NAME (PRINT)
o CITY OF Jt!. TOWN OF C VILLAGE OF
SPECIFY l!) 4PP f~fE.R...
STATE
NAME (PRINT)
SIGNATURE ~