104
0-
N
+
>-
z
W
(/)
W
!Xl
Cl
..J
:l
o
I
(/)
Z
o
i=
<
a:
>-
(/)
a
W
a:
W
"
<
~
a:
<
::;;
L1.
o
W
>-
<
o
LL
i=
a:
W
o
W
a:
W
I
;::
(/)
(/)
W
a:
Cl
Cl
<
i::
(3
W
0-
(/)
+
~~~
1;;;::>-
a:"';S
~~~
:lOW
::;;"5
>-z(/)
z-
Q~~
fEe(/)
0>->-
..UJ~
~~lt)
o~
z::;~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
RohArt Anthony Nicoletti
MIDDLE CURRENT SURNAME
USE CU
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) John C. Mas rson
TIME MONTH YEAR
SEAL SIGNATURE~ DATE 08/11/201
'-- -.J MAILW~ o\D.PIR.E!?:>e AM
-v- ~u MiamI ush Rd, Wappingers Falls, NY 12590 01:23>M 08
STREET CITYITOWN STATE ZIP
~~~R~~~RT~~~ IO~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0,31 RELIGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. ,., PM 0 ~ I ~ 2..0 I. (j 9 0 OTHER, SPECIFY
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c~ 1368 .
~~~I~~~R 1 04
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 115-74-1753
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY!i!'l TOWN 0 VILLAGE
~~~CIFY Hyde Park
D. STREET ADDRESS 107 East Market St
ZIP 12538
YES (!'f NO
/ 19A4
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGE 25 3B. DATE OF BIRTH 11 / ?1
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION S~IAS
B. TYPE OF INDUSTRY OR BUSINESS Cellular
5. PLACE OF BIRTH Bronx, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Thom~s F Nicoletti
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Christine Petillo
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. 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
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
a:
w
'"
::;;
:l
Z
Cl
Z
<
Iii
~
en
o
o
o
21. SIGNATURE OF GROOM~
w
tJ)
z
w
o
~
W
l-
e(
o
i!
i=
ct
w
o
29. OFFICIANT '--:-1
NAME (PRINT) H 0 M ^ ..
SIGNATURE~ ~ ~Yz,Ul-:'l
MAILING ADDRESS
\ 10 f.,ILA hH ..I..t~T' A-I'C-f\)vf:
STREET CITYfTOWN
30. WITNESS TO C
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Joan~D~L1!~arie Fulg~RQ~i SURNAME
-.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Nicoletti
(OPTIONAL - SEE REVERSE) 060 78 6115
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Hyde Park
D. STREET ADDRESS 107 East Market St ZIP 12538
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ct NO
/03 /1985
DAY YEAR
13. A. AGE 24
09
MONTH
13B.DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS Cellular
15. PLACE OF BIRTH White Plains, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Edward G. Fulgenzi
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Madaline R. DiSanzo
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
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
o
o
o 0
o 0
o 0
o 0
. I impedim~t exists
1ST
2ND
3RD
by New York Domestic
25. B. SOLEMNIZATION PERIOO
ENDS AT MIDNIGHT ON,
MONTH
YEAR
DAY
12
2010
10 2010
10
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY WL.Stdu~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF g] TOWN OF 0 VILLAGE OF
c...OLI.-I N ~
(!d/U",->
TITLE /UlM..VJ lAl,"'j..(Di-IC. l'tu~H
aF:..PT. \8.2-010
P L€.A..SA ,...1 T'
DATE
H..ANtl-l L'I a: ruE , N V
STATE' (
NAME (PRINT)
SPECIFY ~O,Jf\J'
NAME (PRINT)
SIGNATURE~