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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Anthon~ Vincent Gesmundo
FIRST IDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~J:~c: 1368
~5~~J~R 12
1. A. FULL NAME
..
"
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE!. 22 66 2375
D. SOCIAL SECURITY NUMBER . I - -
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY~ TOWN 0 VILLAGE
~~~CIFY Pouahkeepsie
D. STREET ADDRESS 2743 Apt B West Main St ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"'''o NO
3. A. AGE 29 3B. DATE OF BiRTH 08 / 1 0 /1980
MONTH DAY YEAR
...
:;
4. EMPLOYMENT
A. USUAL OCCUPATION Technician
B. TYPE OF INDUSTRY OR BUSINESS Rail Road
5. PLACE OF BIRTH Pouahkeepsie. Ny
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Vincent Gesmundo Sr
B. COUNTRY OF BIRTH Italy
7. MOTHER
A. MAIDEN NAME Maraherita Boccia
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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 ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Melissa Marie Bakter
~
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGEGesmundo
(OPTIONAL - SEE REVERS~63_7 4-2611
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A~Y putchess
(STATE) ..t (COUNTY)
c. CHECK ~E hO CITY 0 TOWN 0 VILLAGE
~~~CII:.;:::oug IKeepsle
D. STREET ADDRES~W L;namngvllle Rd ZIP 12590
.,
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATE1 VILLAGE?'>7 0 YIjf.Q,~O
13. A. AG~7 3B. DATE OF BIRTH 0 C:... ~
MONTH DAY YEAR
14. EMPLOYMENT .
A. USUAL occuPATloNResidential Supervisor
Non t-or Profit
B. TYPE OF INDlJl?TRY OflIlUSINESS.
15. PLACE OF BIRTHt-'ougnKeepsle, Ny
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMEFranz Leopold Bakter
'B. COUNTRY OF BIRTJ.' S A
17. MOTHER .,. M . H yt
A. MAIDEN NAME Virginia ane 0
B. COUNTRY OF BIRTHU S A
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D~ORCE CIVIL A~ULMENT
D11TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,'- YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.ose and say that
as to my right to enter into the ma a e
21, SIGNATURE OF GROOM ~
o 0 1ST 0 0
o 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
he best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
. SIGNATURE OF BRIDE~ V\["(\ .~.J21/"\
USE CURRENT NAME 03/12/2010
23. SUBSCRIBED AND SWORN TOIAFFIR
SIGNATURE OF TOWN OR CITY CLE
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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
~ MAI~cr ~F'
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
NAME (PRINT)
SIGNATURE~
DATE
by New York Domestic
TIME
MONTH
MONTH
YEAR
YEAR
AM
03:05PM
05
11 2010
03
13
2010
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY j)~ ~55
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY kJ AfJA-Ni9~;2S fA.["LS
If:. C. (J~ 1R;r
5/1 /to
NAME (PRINT)
SIGNATURE~