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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
R ~ n~~!l~nw~ rrl ~~Jj~~ SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c:1368 .
~~~I:~~R 119
1 . A. FULL NAME
FIRST
0..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)116 64 4267
D. SOCIAL SECURITY NUMBER _ _ _ - __ - ____
2. RESIDENCE A. NY B. n Ilkh A~~
(STATE) (COUNlY)
C. CHECK ONE 0 CITYIlJ TOWN 0 VILLAGE
AND P hk .
SPECIFY nllg AApSIA
D. STREET ADDRESS 2840 Route 90 ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE? 0 YES..o NO
3. A. AGE37 3B.DATEOFBIRTH 1? /n~ /1QRQ
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION RA:::JI FSt:::JtA S:::JIAS
B. TYPE OF INDUSTRY OR BUSINESS Real Estate
5. PLACE OF BIRTH Bronx, New York
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME .Inhn .lnSAph F:::Jllon
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Roberta Sondra Makofsky
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARF,lIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
.DIVORCE...._.._.__....~ -""CIVlL"AJIlNOtMENT'"
o 0
DEATH
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) (CITYICOUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
Lo
~
SUPPLEMENTAL FILE
FROM THE BRIDE
Eileen Patricia Martin
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE F:::J lion
(OPTIONAL - SEE REVERSE)127 70 9148
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A.NY BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY otJ TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
D. STREET ADDRESs2840 Route 9d
ZIP 12590
o YES"6 NO
.t974
YEAR
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE?
13. A. AGE~~ 3B. DATE OF BIRTH 04 )(0
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESSCroton-Harmon S.D
15. PLACE OF BIRTHMount Kisco. NY
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Paul Joseph Martin
. B. COUNTRY OF BIRTJ.J S A
17. MOTHER
A. MAIDEN NAME Diane Mary O'Neill
B. COUNTRY OF BIRTJ.J S A
18. NUMBER OF THIS MARRIAGE 1
19. ~~~~~~~RMo"FR~~AE~~8us MARRIAGES WHICH ENDED BY
.. 'DIVORCE CIVIL ANNULMENT
o 0
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 ANNULlLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (CITY/COUNlY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
o
o
o
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, t
as to my right to enter into the m ge
21. SIGNATURE OF GROO
23. SUBSCRIBED AND SWORN TO/AFFI ED BEFORE E 09/12/2007
SIGNATURE OF TOWN OR CITY C RK ~ DATE
This license authorizes t marriage in New f the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies ithin 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
{ } NAME (PRINT) J . Maste s n
TIME MONTH YEAR MONTH
SEAL SIGNATURE ~. DATE 09/12/2007
I...- -..J MAJ,l,IAlG.AP1Dfll;:>e AM 9
-v- LU MlaaU appingers Falls, NY 12590 05:54 PM 0
STREET CITYITOWN STATE ZIP
~~~R~:Ri~~~ lo~O~~N~Ze'ie 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~ RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
o
o
o
22. SIGNATURE OF BRIDE~
YEAR
13
2007
11 2007
11
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY fJtl7JJlf7I1
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF J:il TOWN OF 0 VILLAGE OF
SPECIFY~ eL - ~t.ef Of:;
~
TITLE 6fn(oLk. fJ~t€ir
NAME (PRINT)
SIGNATURE~