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1 . A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
J ~El P a 1.11 F a~i9RENT SURNAME
I
SIAlto t"ILto NUMlStol1
(THIS SPACE FOR STA TE USE ONL Yi
L 0 SUPPLEMENTAL FILE
-1
FIRST
FROM THE BRIDE
Marta Correia da Silva Soares
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENTda Silva
c. SURNAME AFTER MARRIAGE Soares Fazio
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY
(STATE)
C. CHECK ONE 0 CITY ~
~~~CIFY Phillipstown
D. STREET ADDRES~501 C Route 9
11. A. FULL NAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 075-A.?-!=i?qq
2. RESIDENCE A. N"TATE) B. qc"r\~~';C;
C. CHECK ONE 0 CITY,jZl TOWN 0 VILLAGE
AND \^' .
SPECIFY rvapplnger
D. STREET ADDRESS 4q R Sr.::IrhnroLJgh Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
MOQ~ / ~ / 1~R56
BPutnam
(COUNTY)
TOWN 0 VILLAGE
ZIP 10516
o YES~ NO
.%947
YEAR
3B. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGEn~ 13B.DATE OF BIRTH 06 ~1
MONTH DAY
3. A. AGE 54
4. EMPLOYMENT
A. USUAL OCCUPATION Foundryman
B. TYPE OF INDUSTRY OR BUSINESS T::Illix
5. PLACE OF BIRTH ~IWg~~~~6U~~ IF NOT USA)
6. FATHER
14. EMPLOYMENT
A. USUAL OCCUPATION House Cleaner
B. TYPE OF INDUSTRY OR BUSINESS House Cleaning
15. PLACE OF BIRTHJaragua. GO
(CITY, STATE 1 COUNTRY IF NOT USA)
16. FATHER
A. NAME Jose Correia da Silva
'B. COUNTRY OF BIRTHBrazil
17. MOTHER
A. MAIDEN NAME Angelina Rozeira
B. COUNTRY OF BIRTHBrazil
1 B. NUMBER OF THIS MARRIAGE 2
A. NAME Paul Mario Fazio
8. COUNTRY OF BIRTH It::lly
7. MOTHER
A. MAIDEN NAME Gilrl::l Ri770
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
o
(2) 0 DEATH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
100
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 12 / 28 / 2007
MONT!U DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? t.:J 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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
12/28/2007 Anapolis, GO r1
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
YEAR
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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
D
o 0
o 0
D 0
hat I ,<Jeclare that no legal impediment exists
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1 ST 0 0 1 ST
2ND 0 0 2ND
~ 0 0 ~
~ 0 0 ~
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and
as to my right to enter into the marnage state. / . -
21. SIGNATURE OF GROOM~
07/20/2010
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23. SUBSCRIBED AND SWORN TO/AFFIRMED BE
SIGNATURE OF TOWN OR CITY 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL}
'-.t-I
TIME
MONTH
YEAR
MONTH
YEAR
NAME (PRINT)
DATE 07/20/201
in ers Falls NY 12590 11 :24AM
ITYIT WN STATE ZIP PM
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR D 0 RELIGIOUS 1 ~ CIVIL
9 0 OTHER. SPECIFY
18 2010
07
21
2010
09
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY t1~s.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF p( TOWN OF 0 VILLAGE OF
SPECIFY rl9s-r !1St+YIL L
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
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TITLE
Y;~l)rrteli.
29. OFFICIANT
NAME (PRINT)
...
SIGNATURE~
DOH-98 (09/2009)