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51 A 1E OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Carl Joseph
FIRST MIDDLE
COUNTY Dutchess
~~ffOWN Wap~inger
~~J:~cJ 13 6 8
~G~~J~R 146
1. A. FULL NAME
Di Cocco
CURRENT SURNAME
0-
N
B BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER
2. RESIDENCE A Connecticut
IST.q~,
C. CHECK ONE ~ CITY = TOWN
~~~CIFY Stamford
o STREET ADDRESS 126 Blachley Road
046-70-2604
Fairfield
(COUNTY)
VILLAGE
B.
ZIP 06902
Xi YES = NO
7 /1970
YEAR
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 30 3B. DATE OF BIRTH May /
MONTH
DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Marketing
B. TYPE OF INDUSTRY OR BUSINESS Priceline Webhouse
5. PLACE OF BIRTH Hartf ord, Conne c t icu t
,CITY. STATEiCOUNTRY IF NOT USA)
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Samuel Di Cocco
USA
Barbara
USA
First
Cultrera
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE =ND? '3):::J DIVORCE
C. DATE LAST MARRIAGE ENDED?
13) iJ ANNULMENT
/ /
(2) = DEATH
YEAR
MONTH DAY
D. ARE Af-<Y "ORMER SPOUSE(Si ALIVE' = YES = NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEARI CITY. STATEiCOUNTRY. IF NOT USA) SELF SPOUSE
---,
'---"
'-
I STATE FILE NUMBER I
(THIS SPACE FOR STA TE USE ONL Y)
~ ~ \ J.vlo1>
Lu SUPPLEMENTAL FILE ~
11. A. FULL NAME
FROM THE BRIDE
Gloria A.
FIRST MIDDLE
Cubberly
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B Du tchess
(STATEi (COUNTY)
C. CHECK ONE C CITY XJ TOWN VILLAGE
~~~CIFY Poughkeepsie
o STREET ADDRESS 28 Swenson Drive
WaPDl.ngerS Falls
E. IS RESIDENCE WITHIN LIMITS OF er1'Y OR IrilCoRPORA TEO VILLAGE? n
13. A AGE 28 13.B. DATE OF BIRTH April /29
MONTH DAY
Di Cocco
114-68-8568
12590
ZIP
YES X; NO
/1972
YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION
Unemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Staten Island, New York
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Robert James Cubberly
USA
Anna Valente
Italy
1 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 3) = ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
D. ARE .~NY FORMER SPOUSE(S) ALIVE? = YES = NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE ,HE FOLLOWING :NFORMAT!CN
DATE OF DECREE PLACE ISSUED AGAINST WHC'"
IMONTH. DAY. YEARI (CITY STATEiCOUNTRY. IF "JOT USA) SELF SPOUSE
2) = CEA.-;"
VEAR
1ST
2ND
3RD
n 4TH
of my knowledge and belief that the Information I provided is true
----;
23. SUBSCRIBED ANO SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York S te of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York Slate. THIS LICENSE VALID IN NEW YORK STATE ONLY.
= 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
} NAME (PRINT)~aine H. Snowden, Town Clerk
{ SEAL SIGNATURE~~lt(.Ji~,-- DATE 8/25/00 TIME MONTH DAY YEAR
MAILlfIK> ADO-RESS. 9 : 00 AM
'-.t-I 1'0 lSox 324, Wappl.ngers Falls, NY 12590 PM 8 26 00
STREET CITYfTOWN STATE liP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
~~~sM~~~~g~~v;H~N PiHRe TIME MO. DAY YEAR 0 ~IGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED.
w
en
z
w
o
::i
22. SIGNATURE OF BRIDE ~
25. B. SOLEMNIZATION PERIOO
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
10
24
00
1 = CIVIL
28. PLACE WHERE MARRIAGE OCCUR~
A. STATE NEW YORK B. CO UN fJL /f1:0 S'
tf. C. ,-JK'5-r
Cf? .j./d. H-cJ
1~~Cl
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
C CITY OF 0 TOWN OF ~LLAGE OF
SPECIFY WltPfJl ",61FR S P fH-L $
NAME (PRINT)
31. WITNESS TO
SIGNATURE ~