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COUNTY Dutchess
CITYrrOWN \^'appinger
DISTRICT . .
~~~~~~R 1368
NUMBER 92
::>> I A II: Ut" NI:W YUHI\
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Charl~~o&rthur 8pQ~f6JtAME
FIRST
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
JacgMftline RuseJiaQ,suRNAME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
119741114
B. QM~CSS
VILLAGE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~noncor
(OPTIONAL - SEE REVERSE:)"I'"
D. SOCIAL SECURITY NUMBER OQ4 76-6441
12. RESIDENCE A. NYsTATE) B. q~Ilf3S6
C. CHECK ONE 0 CITY Qo TOWN 0 VILLAGE
AND
SPECIFY Wappinger
D. STREET ADDRESS 4 Long Ct ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES [Wl' NO
~H /09v /1ij4
2. RESIDENCE A. N7{,-ATE)
C. CHECK ONE 0 CITY ~ TOWN 0
AND
SPECIFY Fishl<ill
D. STREET ADDRESS 94 Sterling St ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGE 26 3B. DATE OF BIRTH MO~ / D03
4. EMPLOYMENT
12508
YES 1;1' NO
/ y~~84
13. A. AGE 26
14. EMPLOYMENT
13B.DATE OF BIRTH
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A. USUAL OCCUPATION Sales Rep
B. TYPE OF INDUSTRY OR BUSINESS Office Supplies
5. PLACE OF BIRTH g,Q,~~~i~oNvA)
6. FATHER
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTH L~~\1i~~u~ IF NOT USA)
16. FATHER
.A. NAME Anthony D. Ruscigno
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Mary 6eth N/eni
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A. NAME Charles Arthur Spencer
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Donna Maria Petrizzo
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
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
o
(2) 0 DEATH
o
B. HOW DID LAST MARRIAGE END?
o
(3) 0 DIVORCE
o
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
C. DATE LAST MARRIAGE ENDED?
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) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
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1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that
as to my right to enter into the mari'age st~te. .
21. SIGNATURE OF GROOM. ~ 0..... . NATURE OF BRIDE. .
USE CURR USE CURRENT AME
23. ~~BJ..&~~~Do~N.fo~~Oo~ ci;~A6r~R~E~ BEFORE ME DATE 07/27/201 0
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.
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
o 0
o 0
o 0
o 0
o legal impediment exists
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{ SEAL }
"-v-I
NAME (PRINT)
MONTH
YEAR
TIME
MONTH
YEAR
AM
12:51PM
2010
09
25 2010
07
28
T T
27. TYPE OF CEREMONY
o ~EL1GIOUS
9 0 OTHER, SPECIFY
10 CIVIL
STR
I CERTIFY THAT' SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY TJ..l-/;.f,"'i5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY Fae;1 F;~ k J) (fJcpeu/!/lo.
TITLE 1&"IIQ~1a.ft;()j,t ~/~f
rJ?Jo9/~olt)
I I aZ .~'.
NAME (PRINT)
SIGNATURE~