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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
BriatJoMVilliam JalJJ~ifiI~RNAME
COUNTY DlJtchA~~
CITYfTOWN Wappinger
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~~~I;~~R 111
1 . A. FULL NAME
FIRST
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 122-77-4759
2. RESIDENCE A, N~ATE) B, gcl!\~~ess
C, CHECK ONE 0 CITY WI' TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D, STREET ADDRESS 1 R n AlpinA nr ZIP 12590
E, is RESiDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3, A, AGE 31 3B, DATE OF BIRTH MO~ / D~9 / y:"'~76
4, EMPLOYMENT
A, USUAL OCCUPATION Technical Support
B, TYPE OF INDUSTRY OR BUSINESS Printino
5, PLACE OF BIRTH (t$~~~3t9cR,~Ji!~I~^~oY~r)k
6, FATHER
A, NAME Thomas Harold Jameson
B. COUNTRY OF BIRTH I J S A
7, MOTHER
A, MAIDEN NAME .Ioan Marie \lankl=!llren
B, COUNTRY OF BIRTH J I S A
B, NUMBER OF THIS MARRIAGE 1
9, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
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
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~iw Chiarell<2uRRENT SURNAME
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11, A, FULL NAME
FIRST
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE Chiarello-Jameson
(OPTIONAL - SEE REVERSE)
D, SOCIAL SECURITY NUMBER 05?-70-1330
12, RESIDENCE A, NYsTATE) B, ~prss
C, CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY ~pplngAr
D, STREET ADDRESS 16 [') Alpine Dr ZIP 12590
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r!I' NO
13, A, AGE 35 13B.DATE OF BIRTH 1 n /1 n /1 Q74
MolfiH D"'(Y m'R
14, EMPLOYMENT
A, USUAL OCCUPATION Execllti\le Assistal"t
B, TYPE OF INDUSTRY OR BUSINESS AccOl mting
15, PLACE OF BIRTH Rrnnkl\ln NAW Ynrk
(CITY. STAT~ CdUNTRY IF NOT USA)
16. FATHER
.A. NAME \lito Anthony Chiarello
B. COUNTRY OF BIRTH l J R A
17. MOTHER
A. MAIDEN NAME I inrl~ IrAnA I nmh~rrli
B. COUNTRY OF BIRTH l J R A
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
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o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
owledge and belief that the information I provided is true and
o 0
o 0
o 0
o 0
legal il11JlQlJiment exists
DATE
08/25/2010
by New York Domestic
T~is license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law 911 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
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{ SEAL }
"-v-I
NAME (PRINn
TIME
MONTH
YEAR
MONTH
YEAR
SIGNATURE ~
MAILING ADDRESS
2 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,
DATE 08/25/201
lis NY 12590
STATE ZIP
27. TYPE OF CEREMONY
o]it RELIGIOUS
9 0 OTHER. SPECIFY
11 :5()\M
PM
08
26
2010
10
24 2010
10 CIVIL
28, PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B, COUNTY ~
C, LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 't..TOWN OF 0 VILLAGE OF
SPECIFY P&c7p U-\-
29, OFFICIANT
NAME (PRINT)
TIT~l--f~ Q
SIGNATURE~