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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mi~~8 D8 Si~TSURNAME
COUNTY nlltr.hA~~
CITYfrOWN W::IppingAr
~~~:~c: 1 ~nR
~~~I;~~R 1 ~f)
1 . A. FULL NAME
FIRST
"-
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER xxx - xx - XXXX
2. RESIDENCE A. It~~TE) B. ~~~
C. CHECK ONE 0 CITY ol2I TOWN 0 VILLAGE
AND
SPECIFY Sperlonga
o STREET ADDRESS \Ii::! Cordi (snr.) ZIP 040?9
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
MOQ-~ / ~ / yJA~77
3. A. AGE 33
4. EMPLOYMENT
A. USUAL OCCUPATION Self Employed
B. TYPE OF INDUSTRY OR BUSINESS Tele\li5ion Tech
5. PLACE OF BIRTH Twq~cin~ Ital~
(CI . SATE / C UNTRY IF OT USA)
6. FATHER
3B. DATE OF BIRTH
A. NAME Luigi De Simone
B. COUNTRY OF BIRTH Italy
7. MOTHER
A. MAIDEN NAME Anna Marie Toscana
B. COUNTRY OF BIRTH Italy
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
1ST
2ND
3RD
4TH
I duly swear/affirm, depose
as to my right to enter into th
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
'I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Q~niel::! r,nli1uRRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 11 ~-72-5870
12. RESIDENCE A. Ita1MATE) B. LmL~~)
C. CHECK ONE 0 CITY Q TOWN 0 VILLAGE
AND
SPECIFY SpArlnng::l
D. STREET ADDRESS Via Cardi (snc) ZIP 04029
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES r!'1 NO
13. A. AGE 31 13BDATE OF BIRTH no /24 /'j 97Q
itO.,:!'TH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Informetinn Offir.A
B. TYPE OF INDUSTRY OR BUSINESS RestRurant
15. PLACE OF BIRTH Rrnnx-, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
,A. NAME Gillseppe Goli::!
B. COUNTRY OF BIRTH Italy
17. MOTHER
A. MAIDEN NAME M::Iri::l Col::lntLJono
B. COUNTRY OF BIRTH It::lly
1B. NUMBER OF THIS MARRIAGE 1
19, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
ge and belief that the information I provide
. SIGNATURE OF BRIDE")
USE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
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
NAME (PRINT)
DATE 10/04/201
in ers Falls NY 12590
ITY/T N STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 ~ RELIGIOUS
AM
I .0 PM , 0 _ Cl . ~o, 0 90 OTHER, SPECIFY
29. OFFICIANT'. ~. ;'~ tf I ~I' ,
::~:::~i J"i!:;; -; ~~
MAILING AD~S e
If c.l/I1.ir,..\ '-;.. 6.Jo~~'v1 ~I.s
STREET CI"fY'fi'OWN'
30. WITNESS TO MMONY
NAME (PRINT) ) ec,A
TITLE R".""W\o.M.Mh~
DATE CJct_llt.~OIQ
r 1. 'It.
TE
~
{ SEAL}
'-v-I
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
SIGNATURE~
DOH-98 (09/2009)
o
o
o
o
DATE 10/04/2010
by New York Domestic
TIME
MONTH
DAY
YEAR
MONTH
YEAR
1 0:2~M
PM
10
05
2010
12
03 2010
2B. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY j)lJ;-C'Uf'~ S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF b!l VILLAGE OF
SPECIFY l.v~j)Pr}J{If'Rs ~4LLl
~"'1' C-~ 1-
'~S'<T G
NAME (PRINT)
SIGNATURE~