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COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c: 1368 .
~~~'~~~R 93
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.1::l~&1,t1 n::lniF!1 A!~~~TSURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Daniella Maria Giliberti
MIDDLE CURRENT SURNAME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE AIVF!5:
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 088-70-1366
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY appmger
D. STREET ADDRESS 25 Sherwood Heiahts ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE ?7 13B.DATE OF BIRTH 03 AlA /'f 983
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 074-74-0270
2. RESIDENCE A. NY B. nlltr.hF!~~
(!T ATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY ::lpplnger
D STREET ADDRESS 38 Baldwin Dr
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 30 3B. DATE OF BIRTH 11 /
MONTH
ZIP 12590
o YES~ NO
?? /1979
DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION I ahnr
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH Mt Vernon, N",
(CITY, STATE / COUNTRY IFlIoT USA)
6. FATHER
A. NAME Mcnl1el AlvFl~
B. COUNTRY OF BIRTH Portugal
7. MOTHER
A. MAIDEN NAME Maria Covalho
B. COUNTRY OF BIRTH Portugal
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
14. EMPLOYMENT
A. USUAL OCCUPATION Marketing
B. TYPE OF INDUSTRY OR BUSINESS Advertizing
15. PLACE OF BIRTH Yonkers. Ny
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Claudio Giliberti
'B. COUNTRY OF BIRTH Italy
17. MOTHER
A. MAIDEN NAME Joanne Elisa DeRosa
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) 0 DEATH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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
C. DATE LAST MARRIAGE ENDED?
w
en
z
w
u
:J
1ST
2ND
3RD
4TH
I duly swew/affirm, dep.ose and say, t.
as to my right to enter Into the mamll
/~
USEC
23. SUBSCRIBED AND SWORN 1: /AF MED BEFORE ME
SIGNATURE OF TOWN OR LERK ~
This license authorizes the 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.
o If checked, this license is to be used Dnly for the purpDse of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) , C.
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
o
o
o
o
o
o
o
o
o
o
ent exists
(
USE CURRENT NAME
DATE 07/28/2010
by New York Domestic
~
{ SEAL }
'-v-I
TIME
MONTH
YEAR
MONTH
DAY
YEAR
SIGNATURE ~ DATE 07/28/201
MAI~~ ~& S in ers Falls NY 12590 11 :46AM
STREET CITYITOWN STATE ZIP PM
~~~R~~~Ri~~~ 'o~O~~~N~~E~ 26. SOLEMNIZATION OCCURRED 2:.JPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~ RELlGIOU!> 1 0 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 1- -2()ftJ 90 OTHER, SPECIFY
W
~ ~~~l(~9i~r fel/h-.:JiA.f,'t1 ~'.(/~nf.l'1I-~ TITLEeC- (Prtl<1s+
~ SIGNATURE~ l!L<ft< ~~.f. .~ DATE 9'-/2- 20ft?
i= MAILING ADDRESS ~ A h (k ~ I ~ ~
a:: fO.(3lJ'Y- 4,-~ HtJlPRWe/1 :f{/jV /V~(/ /or ~37
W STREET WTYITOWN STATE ZIP
U 30. WITNESS TO CEREMJ1~/. j ;-/.I 31. WITNESS TO CEREMONY
NAME (PRINT) {flj C 11/LL _ Jr1 ~ >: NAME (PRINT)
~~
07
29
2010
09
26 2010
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYf)ttc. h1fYY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF
SPECIFY t:O\S-r
o VILLAGE OF.- .
(t'S/'l ki j I
,
SIGNATURE~
DOH-98 (09/2009)
SIGNATURE~