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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Eri~M!~hael CSi~SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:kc~ 1368 .
~~~I:J~R 11 8
1. A. FUll NAME
FIRST
"-
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 079-64- 3686
2. RESIDENCE A. NV B. n, It,..~SS
lSTATE) "'rcoriJlfi'Yj
C. CHECK ONE 0 CITY,Ji1J TOWN 0 VILLAGE
~~~CIFY Wappinger
D STREET ADDRESS 5 nnllol~~ nrivp. ZIP 1 ?fi90
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
MJJ~ / ~~ / Ji7Q
3. A. AGE 29
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Carp~nter
B. TYPE OF INDUSTRY OR BUSINESS Constrr Iction
5. PLACE OF BIRTH YcliWs2L~0~~1a~F~~TE'~Afie, NY
6. FATHER
A. NAME Michael Gordon Cii~mar
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Sandra Ii Idith pYE!r!::
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
(2) 0 DEATH
o
o
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
(IH1::>::>I'AIA: rUH ::>fAft; u::>t; UNLYj
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Mic~I~Jla Rae Sb'JWeNT SURNAME
--1
11. A FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c. s~S~~~M..~~~rt~~b~~s~iizmar
D. SOCIAL SECURITY NUMBER 1 ?fi-70-3?fiR
12. RESIDENCE A.N~STATE) B. Dltbtral;w)ss
C. CHECK ONE 0 CITY eJ TOWN 0 VILLAGE
AND W .
SPECIFY ~rrlnop.r
D. STREET ADDRESSS Douglas Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A AGE 27 3B. DATE OF BIRTH tdNTH /-f ~AY -1 ~~p
14. EMPLOYMENT
A. USUAL OCCUPATION M<:ln~ger
B. TYPE OF INDUSTRY OR BUSINESS Retail
15. PLACE OF BIRTH r.itv Of POLJahkp.p.r~ie, NY
(CIlY. STATE / couNTR'y IF NOT USA)
16. FATHER
A. NAME Michael C~rl Selin
B. COUNTRY OF BIRTHI J S A
17. MOTHER
A. MAIDEN NAME .I~np. Marie Gala!;
B. COUNTRY OF BIRTHI J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. - YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
nowledge and belief that the Information I provided is true and ~at I 'CI~th~l "J legB~pedlmen~xists
22.SIGNATUREOFBRIDE~ ~ ~~ )
USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO/ ED BEFORE
SIGNATURE OF TOWN OR CI LERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11to 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
W
UJ
Z
W
o
::::i
~
{ SEAL }
'-..,-I
NAME (PRINT)
DATE
08/27/2008
by New York Domestic
TIME
MONTH
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
DAY
YEAR
YEAR
MONTH
AM
06:25PM
08
28
2008
10
26 2008
.STATE
27. TYPE OF CEREMONY
o iiil1feLIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. cou~~<;' 5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~TY ~ TOWN OF 0 VILLAGE OF
SPECIFY::i2J.. ({-1 ~ ~s 1<::'-
TITLE ri:s- ~J<