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COUilTY
X~~ITOWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thomas John
FIRST MIDDLE
I
STATE ALE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
Dutchess
Wappinger
1368
187
/,o/~1f)()
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Veronica Ann
FIRST MIDDLE
Hout
CURRENT SURNAME
-.J
1. A. FUll NAME
Peccia
CURRENT SURNAME
11. A. FUll NAME
B BIRTH NAME. iF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE P e c c ia
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 050-66-5202
12. RESIDENCEA. New York B.
(STATE)
C. CHECK ONE 0 CITY ~ TOWN
AND P hk .
SPECIFY oug eepS:Le
D. STREET ADDRESS 15 Nassau Rd.
ZIP 12601
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
,STATE) (COUNTY)
o CITY ~ TOWN 0 VILLAGE
Poughkeepsie
15 Nassau Rd.
053-62-7123
Dutchess
(COUNTY)
o VILLAGE
C. CHECK ONE
AND
SPECIFY
D. STREET ADDRESS
ZIP 12601
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES:lti NO
3. A.AGE 28 3B.DATEOFBIRTHNov. /11 /1971 13.A.AGE 28 13B.DATEOFBIRTH June /14 / 1972
MONTH DAY YEAR MONTH DAY YEAR
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Administrated Assistant
B. TYPE OF INDUSTRY OR BUSINESS Coty US LLC
15. PLACE OF BIRTH Dover. New Jersey
(CITY, STATE/COUNTRY IF NOT USA)
A. USUAL OCCUPATION Finane ial Anal ys t
B. TYPE OF INDUSTRY OR BUSINESS AMC
5. PLACE OF BIRTH Brooklyn. New York
(CITY, STATElCOUNTRY IF NOT USA)
16. FATHER
6. FATHER
A. NAME Robert Charles Hout
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Carolyn Motkowicz
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE Fir s t
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A. NAME Anthony Carmine Peccia
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME France!'; Ma!';e 11 a
B. COUNTRY OF BIRTH I tal y
B. NUMBER OF THIS MARRIAGE First
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) C ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES C NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
w
en
z
w
o
::i
o 1ST '-'
o 2ND -' C
o 3RD C
o 4TH C
belief that the information I provided is .trre and that I declate that no legal i~ent exists
t 22. SIGNATURE OF BRIDE. ~l1'\ (j^y\./LtO 1 .-:\\ d'\L;{;
USE CU~M;=I:\
23 ~~BJ~T~~~DO~Nlo~~~:~?vBg~~:~E De ut Town Clerk DATE Sept. 27 .2000
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
CJ 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
Elaine Town Clerk
DATE 9/27/00
NY 12590
TAT
CEREMONY
21. SIGNATURE OF GROOM.
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say,
as to my right 10 enter into the marri
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
'-.t-I
NAME (PRINT
MONTH
DAY
YEAR
MONTH
DAY
YEAR
TIME
SIGNATURE ~
MAILING ADDRES~4
PO Box Jl ,
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
AM
2: 40 PM
6
00
28
00
11
09
ZIP
1 C CIVIL
28. PLACE WHERE MARRIAGE OCCURRED ^ 1....1---
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE ANDjlPECIFY)
o CITY OF bhOWN ~ oVlltr ~J J7
SPECIFY~ ~
29. OFFICIANT
NAME (PRINT)
SIGNATURE.