109
+
>-
Z
W
Ul
W
CD
o
...J
::>
o
I
Ul
Z
o
~
0:
>-
Ul
a
w
0:
w
(!l
<(
a:
0:
<(
:!'
u.
o
w
!;;:
(.)
Ii:
>=
0:
W
(.)
w
0:
w
I
~
Ul
Ul
W
0:
o
o
<(
G:
u
W
0-
Ul
w
en
z
w
0
::::i
+
i€~z W
::>_0
tii~~ ...
0:0:- II(
>-wZ
Ul...J:!' 0
::lOW
:!'(!l5 u:
>-ZUl i=
Z-
o~~ a:
ttocn w
0>->- 0
..W(5
~~"'
o~
Z:J~
STATE OF NEW YORK I STATE FILE NUMBER I
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY Dutchess DEPARTMENT OF HEALTH
CITYfTOWN Wappinger
~~J:~CRT 1368 . AFFIDAVIT, LICENSE and
~5~1~~~R 1 09 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE .-J
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME 'os~~11 Zachary cIJ6?E~iuRNAME 11.A FULL NAME Ari~n~ I ichtAnhArnrr
FIRST FIRST MIDDLE CENT SURNAME
0..
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Ro~~d
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 090-76-1445
12. RESIDENCE A. NY B. [)lltchA~~
(STATE) (COUNTY)
C. CHECK ONE D CITY rY TOWN D VILLAGE
AND P hk .
SPECIFY DUg eepsle
D. STREET ADDRESS 2727 West Main St ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES I!I' NO
O? /OR /1 ~R4
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 ??-7?-0424
2. RESIDENCE A. N;YrATE) B. RMt@ess
c. CHECK ONE D CITY iiil' TOWN D VILLAGE
AND P hk .
SPECIFY 01.0 AAr~IA
D. STREET ADDRESS 25 Streit Ave
ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES I!! NO
MONQH1 / 010 /yl~81
3. A. AGE 29
13. A. AGE 2R
3B. DATE OF BiRTH
13B.DATE OF BIRTH
-...
:;
II(
C
u:
LL
II(
4. EMPLOYMENT
A. USUAL OCCUPATION laborer
B. TYPE OF INDUSTRY OR BUSINESS Con~trLJction
5. PLACE OF BIRTH POllnhkAAn~iA, NAW York
(CITY, S1i{TE / COUNTRY IF NOT USA)
6. FATHER
A. NAME loh'l Craig Rossi
B. COUNTRY OF BIRTH LJ S A
7. MOTHER
A. MAIDEN NAME ShArry I AA Flton
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 0
DEATH
o
14. EMPLOYMENT
A. USUAL OCCUPATION OpAr~tion~ M~n~gAr
B. TYPE OF INDUSTRY OR BUSINESS Hospital
15. PLACE OF BIRTH North Tarrvtown. New York
(CITY, STATE / couN'FRy IF NOT USA)
16, FATHER
A. NAME I Aon~rn AlhArt I ichtAnhArger Jr
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Cheryl Ann Apostolico
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
o 0
DEATH
o
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
c. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT (2) D DEATH
/ (
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
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
~
::>
z
o
z
'"
tu
w
0:
~
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and s,t
as to my right to enter into the rna
21. SIGNATURE OF GROOM~
D D 1ST
D D 2ND
D D 3RD
D D 4TH
e best of my knowledge and belief that the information I provided is true and that I declare that
e. ~
D D
D D
D D
D D
legal impediment exists
USE R EN NAME
23. SUBSCRIBED AND SWORN TO/AF RMED BEFORE ME
SIGNATURE OF TOWN OR CITY LERK ~
This license authorizes e marriage in New York State of the bride and groom named above by any person authorized
Relations Law 911 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
r-"-., 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Jo C. Mas rson
TIME MONTH DAY YEAR
SEAL SIGNATURE~ DATE 08/23/201
MAILING ADDRES~ AM
"-v-' 20 Middle sh Rd. Wappinaers Falls. NY 12590 03:5J>M 08
STREET CITYfTOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
~~~SM~~~~~~B~V;Hci'N PTEHRe TIME MO. DAY YEAR O.a1!iELiGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 D OTHER, SPECIFY
'Vx
DATE 08/23/2010
by New York Domestic
MONTH
YEAR
24
2010
10
22 2010
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~(' tf~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF y-r6WN OF ~ tiLLAGE OF
SPECIFY UIfJI tJlJ ~
NAME (PRINT)
SIGNATURE~
DOH-98 (09/2009)