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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rob~i'~.nthony ~~fWI'1URNAME
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to the best
as to my right to enter into the marnage state
21. SIGNATURE OF GROOM~
S
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New rk 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
COUNTY nlltr.hp.~~
CITYITOWN W~rringp.r
~~~~~c; 1 36R .
~5~1~~~R 14~
1. A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 127 -58-5984
2. RESIDENCE A. NV B. n"t,..hess
(liT ATE) "fl5BUi1'ffi'
C. CHECK ONE 0 CITY 0 TOWN oI2l VILLAGE
~~~CIFY Millbrook
D. STREET ADDRESS 62 Harts \lillaQI'! Rn~rl ZIP 1 ?~4~
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VilLAGE? IS1I' YES 0 NO
MOOO / DW / ylj69
3. A. AGE 41
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Union Laborer
B. TYPE OF INDUSTRY OR BUSINESS ~'Jn,tr' Il"t;O"'l
5. PLACE OF BIRTH ~R~~~~~J?~i~ NO~tXA)
6. FATHER
A. NAME Thomas Franklin Green
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Edna Lee Allan
B. COUNTRY OF BIRTH I I S A
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
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 STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sha~DglJ Marie ArcID~t9suRNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SYS~~JN~~~~~t~~~~~s~reen
D. SOCIAL SECURITY NUMBER 0~n-n4-R~?0
12. RESIDENCE A. NY
(STATE)
C. CHECK ONE 0 CITY 0
~~~CIFY Millhrnnk
D. STREET ADDRESS n? H~rts Village Road ZIP 12545
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? ~ YES 0 NO
13. A. AGE 29 13BDATE OF BIRTH ------rJOQTH /2~y /-j' ~Q
14. EMPLOYMENT
A. USUAL OCCUPATION Homemaker
B. TYPE OF INDUSTRY OR BUSINESS Hnmpm~kpr
15. PLACE OF BIRTH Pnllnhkp.l'!n~il'! Nv
(CITY, s'i'l\ TE / COUmRY IF NOT l1sA)
16. FATHER
B.~SS
TOWN Q VILLAGE
A. NAME Frank Armato
'B. COUNTRY OF BIRTH I J ~ A
17. MOTHER
A. MAIDEN NAME ~11~~n Rp.nnp.tt
B. COUNTRY OF BIRTH I J ~ 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) D 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 1ST
o 2ND
o 3RD
o 4TH
nd belief that the information I provid
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{ SEAL }
\.J..v-'
NAME (PRINT)
22. SIGNATURE OF
DATE
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
DATE 10/18/201
F II NY 12590
STATE ZIP
27. TYPE OF CEREMONY
17 2010
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
AM
03:5ClPM
10
19
2010
12
i~L
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~l" ~~~:;
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF D VILLAGE OF
SPECIFY iUS'. /f/~ e r