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STATE Of,;NEW~YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert John
FIRST MIDDLE
COUNlY Dutchess
~;irOWN Wappinger
~~~:~<;J 1368
~5~~J~R 105
1. A FUll NAME
Loscalzo
CURRENT SURNAME
Q.
N
B BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER
2. RESIDENCE A New York
\STATEJ ~
c. CHECK ONE = CITY ~ TOWN 0
AND W'
SPECIFY appl.nger
D. STREET ADDRESS 404 popula Blvd.
067-40-0269
B Dutchess
(COUNTY)
VILLAGE
ZIP
12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 43 38. DATE OF BIRTH Aug. / 06 /1956
MONTH DAY YEAR
4. EMPLOYMENT
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A. USUAL OCCUPATION Printer
8. TYPE OF INDUSTRY OR BUSINESS Banta Corporation
5. PLACE OF BIRTH Queens , New York
,CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
B. NUMBER OF THIS MARRIAGE
Anthony Loscalzo
USA
Joan Musticchio
USA
Second
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
One
DEATH
8. HOW DID LAST MARRIAGE END? (3) 00 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C DATE LAST MARRIAGE ENDED? March / 16 / 2000
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES D NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEARI ,CITY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
3/16/00 poughkeepsie, NY Xl w
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I STATE FILE NUMBER I
(THIS SPACE FOR STATE USE ONLY)
./ -'1\1\ O~
Lo SUPPLEMENTAL FILE ~
11. A- FUll NAME
FROM THE BRIDE
Brenda L. Rasmussen
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Loscalzo
(OPTIONAL. SEE REVERSE) 049-58-3426
D SOCIAL SECURITY NUMBER
12. RESIDENCE A- New York B. Dutchess
(STATEI (COUNTY)
C. CHECK ONE o CllY ~ TOWN VILLAGE
AND Wappinger
SPECIFY
D. STREET ADDRESS 404 popula Blvd. ZIP
12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR rNCCRPORATED VILLAGE?
13. A. AGE 42 13.B. DATE OF BIRTH Sept. /15
MONTH DAY
YES Xl NO
/1957
YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Bindery Worker
B. TYPE OF INDUSTRY OR BUSINESS Banta Corporation
15. PLACE OF BIRTH Danburv. Connecticut
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
18. NUMBER OF THIS MARRIAGE
Henry Rasmussen
USA
Baczmarga
Margaret
USA
Third
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
Two
DEATH
B. HOW DID LAST MARRIAGE END? i3iX! DIVORCE i31 = ANNULMENT 21 c.... DEATH
C DATE LAST MARRIAGE ENDED? N OV . / 26 / 1 997
MON1Jj. DAY vEAR
D. ARE ANY FORMER SPOUSE(Sl ALIVE? ~ YES = NO
20 iF PREVIOUSLY DIVORCED OR ANNUlED. PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED .~GAINST WHOM
iMONTH. DAY. YEAR) ,CITY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
11/14/80 Danbury, Connecticut ~
11/26/97 Danbury, Connecticut ~
25. B. $Ol.EMNIZATKlN PERIOD
ENDS AT MIDNIGHT ON:
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY I 0'"
(CHECK ONE AND SPECIFY) .
= "'" 0' = row."" r'""" if. lL
SPECIFY MJ".pPJ~ ~
NAME (PRINT)
SIGNATURE.
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