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COUN!y
X4l~fTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Richard 1.
FIRST MIDDLE
I STATE ALE NUMBER I
(THIS SPACE FOR STATE USE ONLY)
11'~ ~J1110D G
Lo SUPPLEMENTAL FILE ..J
Dutchess
Wappinger
1368
164
FROM THE BRIDE
Melissa A.
FIRST MIDDLE
Baccomo
CURRENT SURNAME
1. A. FULL NAME
Koretsk~
CURRENT SU NAME
11. A. FULL NAME
B BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Ko r e t sky
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 083- 58-98 71
12. RESIDENCEA N~~TErork B. (Poi}~hess
c. CHECK ONE 0 CITY 181 TOWN 0 VILLAGE
AND
SPECIFY Hyde P:irk
D. STREET ADDRESS 18 Rennert Rd ""
~Keeps~e l~Y
E. IS RESIDENCE WITHIN L1MI1'S' OF CITY dR INCOR~ORATED VILLAGE? 0
13. A. AGE 11 13.B. DATE OF BIRTH Nnv /1 h
MONTH DAY
YES Xl NO
XQhR
YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York
(STATE)
o CITY ~ TOWN
Hyde Park
095-60-0808
B. (CO~N~~chess
o VILLAGE
C. CHECK ONE
AND
SPECIFY
ZIP 1 ?601
ZIP 12601
o YES Xl NO
1 Q /1 Q6 7
DAY YEAR
14. EMPLOYMENT
D. STREET ADDRESS
e,
E. IS RESIDENCE WITHiN LIMIT OF CITY 0 INCORPORATED VILLAGE?
3. A. AGE 33 3B. DATE OF BIRTH Apr; 1 /
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Servi ce M:inager
B. TYPE OF INDUSTRY OR BUSINESS Pnllghkpppl';; p Mi tl';llhi l';hi
15. PLACE OF BIRTH FavpttPv;llp.North r..<lrolina
(CITY, STATE/COUNTRY IF NOT uSA)
16. FATHER
A. NAME Cosmo F. Baccomo
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Connie A. Cas t i g 1 ione
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE Second
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRiAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
One
w
....
'"
....
'"
A. USUAL OCCUPATION Self Emplovpd
B. TYPE OF INDUSTRY OR BUSINESS Auto S:i 1 el';
5. PLACE OF BIRTH Mt. Kisco,_ New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A NAME Ronald G. Koretsky
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME
T. Reilly
Lillian
USA
8. NUMBER OF THIS MARRIAGE Fir s t
B. COUNTRY OF BIRTH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
(2) 0 DEATH
8. HOW DID LAST MARRIAGE END? (31K1 DIVORCE 131 L ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? April /14 /1998
MONTH ~A Y YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? JtJ YES L NO
20. iF ?REVIOUSL Y DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
',MONTH. DAY. YEARI (CITY, STATEiCOUNTRY, IF NOT USA! SELF SPOUSE
1ST 4/14/98 Dutchess Co. New York ~
B. HOW DID LAST MARRIAGE END?
(3) C DIVORCE
(3) 0 ANNULMENT
/ /
YEAR
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? CJ YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) ICITY. STATEiCOUNTRY, IF NOT USA) SELF SPOUSE
w
en
z
w
(,)
::i
o
o 2ND
o 3RD
o ;- 4TH w :J
t of my knowledge and belief that the information 1 provided is true and that I declare that no legal impediment exists
22. SI ATURE OF BRIDE ~ /JJfJ ).lYJtL/ Q - iW/!i mLQ
riA. USE CURRENT NAME 9 /. 1/'11'.
23. SUBSCRIBED AND SWORN TO BEFORE ME II l-L.I
SIGNATURE OF TOWN OR CITY CLERK ~ I DATE
This license authorizes the marriage in New York State of the bride and groom named above y 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.
o If checked, this license is to be used onl for the purpose of a second or subsequent ceremony,
24. TOWN OR CITY CLERK 25. A SOLEMNIZATION PERIOD BEGINS
Elaine H. Snowden Town Clerk
DATE 9 /11/00
NY 12590
A
27. TYPE OF CEREMONY ...
RELIGIOUS 1 ~VIL
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, tha
as to my right to enter into the marriage
L.......i
o
21. SIGNATURE OF GROOM ~
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL}
'-.t-I
NAME (PRIN
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
AM
10:3~M 09
SIGNATURE
MAILING ADDR
P.u.Box
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
o
12
00
11
10
ZI
2B. PLACE WHERE MARRIAGE OCCURR~ &'"
A. STATE NEW YORK B COUN~
C. LOCATION .OF CEREMONY I::J
(CHECK ONE AND ECIFY)
OTHER, SPECIFY
SPECIFY
NAME (PRINT)
SIGNATURE~ ·
lXlH-98 (11ll8)