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1 . A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Sal\latgl~~EFr~nk COC~~R~~'t~ME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Yi
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~: 1368 .
~~~~~~R 120
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME FIRST M::IM~DLl;lelen Ca~&R~lNTSURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT \/el::l7'lIIA7
C. SURNAME AFTER MARRIAGE r.::I~~nnettn
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 127-60-297 4
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNlY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 17 Clapp Ave ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 11 YES 0 NO
O? /03 A 970
MONTH DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 10fi-66-33?3
2. RESIDENCE A. N;t,.ATE) B. Q!~t~~ess
C. CHECK ONE 0 CITY 0 TOWN fiii'I VILLAGE
~~~CIFY W::lrringer~ F::III~
D. STREET ADDRESS 17 Clapp Ave ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE 40 3B. DATE OF BIRTH n1 / n5 / 1 Q70
MON'fH D~ YEA'Il"
13. A. AGE A.n
13B.DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION FDNYF~~
B. TYPE OF INDUSTRY OR BUSINESS EMS
5. PLACE OF BIRTH Rrnny New York
(CllY, STATE 1 CDUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION CSR
B. TYPE OF INDUSTRY OR BUSINESS Advertising
15. PLACE OF BIRTH Manhattan. New York
(CllY, STATE 1 CDUNTRY IF NOT USA)
6. FATHER
16. FATHER
A. NAME Cicilio Vel::l7quez
'B. COUNTRY OF BIRTH Puerto Rico
17. MOTHER
A. MAIDEN NAME Marlene Padilla
B. COUNTRY OF BIRTH Puerto Rico
1 B. NUMBER OF THIS MARRIAGE 3
A. NAME Frank I Cassonetto
B. COUNTRY OF BIRTH l J S A
7. MOTHER
A. MAIDEN NAME M::Irion I ongo
B. COUNTRY OF BIRTH l J S A
B. NUMBER OF THIS MARRIAGE 2
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9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT DEATH
1 0 0 2 0 0
B. HOW DID LAST MARRIAGE END? (3) D"'DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) dDIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 04/ 1 fi / 2009 c. DATE LAST MARRIAGE ENDED? 08/ 08 / 2006
MONTH DAY YEAR MONTH DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? [tYES 0 NO
.
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CllY/COUNlY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CllY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 04/15/2009 Nassau County. New York 0 d 1ST 08/08/2006 Poughkeepsie, New York d'" 0
2ND 0 0 2ND 11/06/1991 Bronx, New York ct 0
3RD 0 0 3RD 0 0
UH 0 0 UH 0 0
I duly swear/affirm, depose and sa I that to the best Df my knowledge and belief that the information I provided is true and that I declare that no legal impediment exist
as to my right to enter into the g ~ . / /
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF ilRIDE~ ~-<'
USE C)JI111E
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK" DATE
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 secDnd or subsequent ceremDny.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL}
. "-v-'
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
SIGNATURE" DATE 09/02/201
MAILING ADDR
20 Mi in ers Falls NY 12590
STREET CllYlTOWN STATE ZIP
~~~R~~~RT~~~ IO~O~~~N~:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 00 RELIGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. 6 : 30 p 9 2 5 20 1 0 9 0 OTHER, SPECIFY
29 OFFICIANT Reverend Dr. Eric C. Mallet-t-eClergyman
NAME (PRINT) TITLE
SIGNATUR:;- ...;z--~ " ~ C. rn J.1.JJt:--DATE 9 /25 /20 1 0
M~ILJtlQ. ADEDRaESs~t
IL~ Mer ck Road Freeport NY 11520
AM
12:2&M
09
03
2010
11
01 2010
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY N ass a u
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY Hemps tead
10 CIVIL
STATE
oj
SIGNATURE"
DOH-98 (09/2009)