067
0-
N
+
o
0>
L{)
N
~
>-w
Z!;[
Ii;
Ul
Ul
W
a:
o
o
<(
~
(3
W
0-
Ul
+
~~~ W
~~~ ....
t;;~~ oc(
::lOW
::!<!)5 u::
t-ZUl
~~15 t:
itaUl W
~~~ 0
I!!~",
OW
z~h;
COUNTY Dutchess
CITYfTOWN Wappinaer
~~~:f: 1368 .
~5~~l~R67
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
John Casino
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Tammy Marie Pardee
MIDDLE CURRENT SURNAME
.-J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEb68 68 2714
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITYo,(] TOWN 0 VILLAGE
~~CIFY Wappinger
D. STREET ADDRESS 133 New Hackensack Rd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YEs'"'b NO
3. A. AGE40 3B. DATE OF BiRTH 07 /04 /1969
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Maintenance Technician
B. TYPE OF INDUSTRY OR BUSINESS Nursina Home
5. PLACE OF BIRTH Mount Vernon. Ny
(CITY, STATE / COUNTRY IF NOT USA)
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGECasino
(OPTIONAL - SEE REVERSro87 -56-3891
D. SOCIAL SECURITY NUMBER
12. RESIDENCE l:>:!Y BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITYootJ TOWN 0 VilLAGE
~~CIFYWappinger
D. STREET ADDRESS133 New Hackensack Rd
ZIP 12590
o YES"'D NO
)966
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE?
13. A. AGe43 3B. DATE OF BIRTH 10 24
MONTH DAY
....
:;
c(
6. FATHER
A. NAME Vincent Casino
B. COUNTRY OF BIRTH Italv
7. MOTHER
A. MAIDEN NAME Marie La Falce
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATIO~urse
B. TYPE OF INDUSTRY OR BUSINESsNursing Home
15. PLACE OF BIRT~eacon, Ny
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEEdward Charles Pardee
. B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAME Dorothy Irene Messerich
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 2
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 0 1 0 0
B. HOW DID LAST MARRIAGE END? (3) tJ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (~ 0 DEATH
C. DATE LAST MARRIAGE ENDED? 05 / 10 / 2010' c. DATE LAST MARRIAGE ENDED? 04 / 08 / 1994
MONTH DAY YEAR MONTjj/ DAY ~ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? [] YES 0 NO
~
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST 05/10/2010 White Plains, Nv 0 ~ 1ST 04/08/1994 Poughkeepsie, Ny ~
~ 0 0 ~
~ 0 0 ~
~ 0 0 ~
I duly swear/affirm. dep.ose and say, that to the best of my knowlepge and belief that the information I provided is
as to my right to enter into the mamage state.
W
en
z
W
o
::::i
USE CUR
23. SUBSCRIBED AND SWORN T FIRMED BEFORE ME
SIGNATURE OF TOWN OR 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 If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITYJ CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)
MONTH YEAR
SEAL SIGNATURE ~
"-v-I MA~oGrC1i'm
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
J>k.~
by New York Domestic
MONTH
YEAR
2010
08
16 2010
06
18
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVil
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF >>TOWN OF 0 VILLAGE OF
SPECIFY ~~~ ~;~~~ I LL ~
29. OFFICIANT
NAME (PRINT)
TITLE ~r./
DATE ? /3 )Jd
STATE
NAME (PRINT)
SIGNATURE~