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COUNTY Dutchess
CITYITOWN Wappinger
~~J:~:1368 '
~5~I:J~R9
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Laura Marie Fasano
FIRST MIDDLE CURRENT SURNAME
B, BIRTH NAME (MAIDEN NAME), IF DIFFEREN~ eipert
c, SURNAME AFTER MARRIAGEPorpiglia
D. s~~~~~~~I~~~~~RS~ 33-52-0782
12, RESIDENCE ~Y BDutchess
(STATE).L. (COUNTY)
C. CHECK ONE 0 CITY~U TOWN 0 VILLAGE
~~cl~ishkill
0, STREETADDRES~05 Clermont Lane ZIp1Zb!::lU
.t.
E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES g NO
13. A, AGQ2 3B. DATE OF BIRTH 09 ;to )'9 7
MONTH DAY YEAR
1. A. FULL NAME
\Iin~Ant .Jn~Aph pora~lia
MIDDLE C R NT SURNAME
11, A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEh
0, SOCIAL SECURITY NUMBER 55-46-2809
2, RESIDENCE A. NY B. nut chess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY.,{J TOWN 0 VILLAGE
~~CIFY Fi~hkill
0, STREET ADDRESS 305 Clermont Lane ZIP 12590
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEs"'b NO
n~ /31 /1953
MONTH DAY YEAR
3B, DATE OF BiRTH
3. A, AGE 56
4. EMPLOYMENT
A, USUAL OCCUPATION BII~inA~~ An:::ilyst
B. TYPE OF INDUSTRY OR BUSINESS Capital Market
5. PLACE OF BIRTH Rrnnklvn I New York
(CITY, STAir/COUNTRY IF NOT USA)
6, FATHER
A. NAME \Iinc~nt Anthnny Pnrpigli:::i
B, COUNTRY OF BIRTH Italy
7, MOTHER
A, MAIDEN NAME .IAnniA G Albino
B, COUNTRY OF BIRTH l J S A
8. NUMBER OF THIS MARRIAGE 3
14. EMPLOYMENT
A. USUAL OCCUPATIONCounselor
B. TYPE OF INDUSTRY OR BUSINESsEducatlon
15. PLACE OF BIRTHBuffalo, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEHenrv Veipert
'B. COUNTRY OF BIRT~razil
17. MOTHER
A. MAIDEN NAME Mary Elizabeth McMahon
B. COUNTRY OF BIRT~ S A
18, NUMBER OF THIS MARRIAGE 2
c
~
Iii
~
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 D~TH
2 0 0 1 0 U
B. HOW DID LAST MARRIAGE END? (3) f!1 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) ~ANNUlMENT (O~ DEATH
C. DATE LAST MARRIAGE ENDED? 11 / 27 / 2000 C. DATE LAST MARRIAGE ENDED? 08 L 0 / 20
MONTH DAY YEAR MONT~ DAY' / YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
OATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATEICOUNTRY, IF NOT-USA) SELF SPOUSE
111?7/?nnn Gn~hen, New York 0 ~ 1ST 08/20/2008 White Plains, New York 0 ~
n7/17/1981 Richardmond County, New ~ 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
now~dge ~ ~elief that the information I provided Is t e and that I declare that legal impediment exists
~ 2. SIGNATURE OF BRIDE ~ ~MA/1 /. rm
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.ose and say,
as to my right to enter Into the am
21. SIGNATURE OF GROOM
DATE
by New York Domestic
23. SUBSCRIBED AND SWORN FFIRMED
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 II checked, this license is to be used only for the urpose 01 a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) n
r-I'-.
{ SEAL }
'-..t-I
YEAR
MONTH
YEAR
TIME
MONTH
DATE 02/19/201
in ers F ails NY 12590
ITYtr WN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME AY YEAR 0 0 RELIGIOUS
AM
: f 0 PM () 2.. z., ;t.o I 0 9 0 OTHER, SPECIFY
514 1-11 A ft);U: A. !.A($)1f) Ml
10:12AM
PM
02
20
2010
04
20 2010
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY UJE~rC:H
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY 'YDR.14TOWN
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1 'JCl CIVIL
29. OFFICIANT I-/~
NAME (PRINT)
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~