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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c: 1368 .
~~~I~~~R 11 0
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFADAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
G~FcML~ohn Nel~~ SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Mir.hAIIA SpA7i;:!IA
MIDDLE CURRENT SURNAME
-.J
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Nl=\wm;:!n
(OPTIONAL. SEE REVERSE) 113 72 7164
D. SOCIAL SECURITY NUMBER _ _ _ - __ - _ _ __
12. RESIDENCE A. f'JY B. nlltr.hASS
(ST ATE) (COUNTY)
C. CHECK ONE 0 CITY [Y TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 95 New Hackensack Rd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES r! NO
13.A. AGE 29 13B.DATE OF BIRTH 01 /~O /HIR1
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Front Fnrl SlJpArvisor
B. TYPE OF INDUSTRY OR BUSINESS Home Depot
15. PLACE OF BIRTH Bronx, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A, NAME .lm::Aph SpA7i;:!IA
'B: COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Nanette Caruso
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
B. BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 ? 4-~4-7Q~ 1
2. RESIDENCE A. N~ATE) B. -go~~~ess
C. CHECK ONE 0 CITY Iil TOWN 0 VILLAGE
AND IAI .
SPECIFY vvapplnOl=\r
D. STREET ADDRESS Q!i NAW H;:!ckAnsack Rd
ZIP 12590
E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES r!!f NO
MON~1 / 0~5 / yJ~60
3. A. AGE 50
38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Tool Rental Associate
B. TYPE OF INDUSTRY OR BUSINESS HnmA nApnt
5. PLACE OF BIRTH M;:!nh;:!tt;:!n NAW Ynrk
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
....
:>
<C
Q
u:
LL
<C
A. NAME Robert '^' NelMman
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME .lor.rJlIAlinA.1 Titk;:!
B. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
w
en
z
w
o
::i
o
B. HOW DID LAST MARRIAGE END? (3) [JoItllVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 01/ O? / ?OO? C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR MONTH DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? Oo,f'ES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 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) (CITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH. DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
01102/?00? Pnughkeepsie, New York D"" 0 1ST 0 0
o 0 ~D 0 0
o 0 3RD 0 0
o 0 4TH 0 0
est of my knowledge and belief that the information I provided is true and th~t I declare that nO~1 gal impediment exists
2 SIGNATURE OF BRIDE....-'11t (.l.l~ Il _~(/, l c-,i /
USE CU '--v USE 1:tiIfRENT NAM IL/
23. SUBSCRiBED AND SWORN TO/AFFIRMED BE ORE ME 08/24/2010
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 second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
C. Mas
1
1ST
2ND
3RD
4TH
I duly swear/affirm. depose and say,
as to my right to enter into the m rI
21, SIGNATURE OF GROOM ~
~
{ SEAL }
~
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
DATE 08/24/201
ush Rd. Waopingers Falls. NY 12590
CITYITOWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR
~ AM
SIGNATURE ~
MAILING ADDRESS
20 Middle
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
11 :5J.M
PM
08
25
2010
10
23 2010
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
1 i:!reIVIL
29. OFFICIANT
NAME (PRINT)
SPECIFY
ZI
31. WITNESS TO CEREMONY
.:D CU\ ~ t\ \(...
1:) l>J'..' { 1 U
U.J\ \-
Lu--
NAME (PRINT)
SIGNATURE~