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1. A FUll NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Nir.hol;:l~ Anthon\/ M;:lr7ovill::l
FIRST MIDDLE J CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITYITOWN Wappinger
~~~~~c~ 1368
~~~I~;~R 46
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
AnM~~>D~arie Pur~MRRENT SURNAME
~
11. A. FULL NAME
<l.
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Marzovilla
(OPTIONAL. SEE REVERSE)060 74 9406
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE ANY BDutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY 'i1"'J TOWN D VILLAGE
~~~CIFY Wappinger
D. STREET ADDREss615 Chelsea Cay
....
:>
<
c
u::
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 055- 74-3401
2 RESIDENCE A NY B. nlltr.hp.~~
(STATE) (COUNTYI
C. CHECK ONE D CITY 'o!'J TOWN D VILLAGE
AND W .
SPECIFY ::lprrnger
D. STREET ADDRESS 615 Chelsea Cay ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES oCJ NO
3. A. AGE 22 3B. DATE OF BIRTH 11 / 11 /19RS
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Control r.p.ntp.r Opp.r::ltor
B. TYPE OF INDUSTRY OR BUSINESS ~emi Conductor
5. PLACE OF BIRTH POI tnhkp.p.n~ip. NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Stephen Pall' Marzovill8, Sr
B. COUNTRY OF BIRTH l J ~ A
7. MOTHER
A. MAIDEN NAME T p.rp'!=:;:l r.::l!=:trnvinr.i
B. COUNTRY OF BIRTH I J ~ A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE .CIVIL ANNULMENT
DEATH
o
ZIP 12590
D YES ~ NO
A986
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE? 1 3B. DATE OF BIRTH 10 A52
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Eligibility Clerk
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH Bronxville. NY
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Allen Thom::ls Purdy
, B. COUNTRY OF BIRTHU S A
17 MOTHER
A. MAIDEN NAME Kathleen Marie O'Toole
B. COUNTRY OF BIRTHU S A
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
o
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
c. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / (,
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
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
1ST
2ND
3RD
4TH
r duly swear/affirm, depDse and say, that to the best of my
as to my right to enter into the~ar(I~~ state. .
21. SIGNATURE OF GROOM~ UI~
SE C
23, SUBSCRIBED AND SWORN TO/AFFIRMED BEFO M
SIGNATURE OF TOWN OR CITY CLERK ~
D D 1ST
D D 2ND
D D 3RD
D 0 4TH
nowledge and belief that the information I provided is tru
D
D
D
This 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.
D 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
by New York Domestic
~
{ } NAME (PRINT) lohn y M;:ljtp.r~on
SEAL ~~~~~~6~ESS ~ C 1t4~ J DATE 05/06/2008
'-.t-I STR~ l\~iddlE'bIlSh Rei. \N;:lpg~~r~ F;:lIl!=:'sT~1 1?59Qp
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION 0 CURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIAN~
NAME (PRINT)
TIME
MONTH
YEAR
MONTH
YEAR
AM
03:04PM
2008
07
05 2008
05
07
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~
C. LOCATION OF CEREMONY
(CHECK ONE AND )pECIFY)
D CITY OF ~OWN OF D VILLAGE OF
SPECIFY W tf:rlOPJ ~ ~
RELIGIOUS
CIVIL
NAME (PRINT)
SIGNATURE~
DOH-98 (03/2006)
NAME (PRINT)
SIGNATURE~