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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~: 1368
~~~I~J~R 144
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
EriG ~Py M~r.~r~Q9r
10 L C NT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Adri;:m~ NicolA Fasano
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 M~r.r,rAgnr
(OPTIONAL - SEE REVERSE) 071 70 2560
D. SOCIAL SECURITY NUMBER __ _ - __ - ____
12. RESIDENCE A. NY B. nlltchASS
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VilLAGE
AND W '
SPECIFY appmger
D. STREET ADDRESS 83 Chelsea Rd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
/On /f 9R.:1
DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER OnO-7?-7nS9
2. RESIDENCE A. N';(TATE) B. 9c~t~ess
c. CHECK ONE 0 CITY oIZI TOWN 0 VILLAGE
AND W '
SPECIFY ~pplngAr
D STREET ADDRESS 83 Chelsea Rd
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
MO!J~ / D~ / yl~83
13B.DATE OF BIRTH
11
MONTH
13. A. AGE 2~
3. A. AGE 27
3B. DATE OF BiRTH
4. EMPLOYMENT
A. USUAL OCCUPATION H\lAC Tech
B. TYPE OF INDUSTRY OR BUSINESS HV AC
5. PLACE OF BIRTH Mount Kisco NAw York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME William ~indlAY M8cr,rAonr
B. COUNTRY OF BIRTH l J S A
7. MOTHER
A. MAIDEN NAME I ~IJr~ Louise KropAlnicki
B. COUNTRY OF BIRTH LJ S A
6. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Te~chAr
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTH White Plains, New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME StAphAn VincAnt F~s~no
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Laura Rizzo
B. COUNTRY OF BIRTH Argentina
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
o
DEATH
o
(2) 0 DEATH
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
13) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
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
w
U)
Z
W
u
::J
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is~ed that I declare that no legal impediment exists
as to my right to enter into the mage state.
e'
21. SIGNATURE OF GROOM~ 22. S NATURE OF BRIDE~
USE C -t,. rv USE CURRENT NAME
23. ~~~;:~~~Do~N.fo~~"tRNd;~A~r~:E~BEFORE ME AV ~ DATE 10/12/2010
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
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 25. B ~~5~MA~~~~~m~~D
{ } NAME (PRINn JO~n TIME MONTH DAY YEAR MONTH DAY
SEAL SIGNATURE ~
\-. .-J MAII,l~ ~qr;>IIFlE~Seb AM 10 13 2010 12 11 2010
-v- STRE~U M am 03:02PM
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
T1TlE~
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 1>1L\t}~
C. LOCATION OF CEREMONY
(CHECK ONE AN~CIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY ~.5 ~ ~ i ~ l..
.
NAME (PRINn
SIGNATURE~
DOH-98 (09/2009)
NAME (PRINT)
SIGNATURE~