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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mir.h~el nnmenir.k St~tile
MIDDLE CURRENT SURNAME
USE
23. SUBSCRIBED AND SWORN TOIAFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of
Relations Law ~11 to perform marriage ceremonies within New York te. 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 LER~ M 25. A. SOLEMNIZATION PERIOD BEGINS
r- ~ } NAME (PRINT) JI n \J. sterson
{SEAL SIGNATURE ~ DATE 08/30/2007 YEAR
'-v-I M~<>rooffi1ft ush R , Wappingers Falls, NY 12590
STREET CITYITOWN STATE ZIP
~~~~~Ri:~ IO~O~~N~Z:t=P- 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. 0 Y YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
29. OFFICIANT --:-::::>
NAME (PRINT) ~~
~:;p
DATE ..,
rJ~
COUNiY Dutchess
CITYfTOWN Wappinger
~~~~~: 1368 .
~5~1;~~R 1 06
1. A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 140-60-5232
2. RESIDENCE A. Ne B. New H~nnver
(STATE) (COUNTY)
C. CHECK ONE olJ CITY 0 TOWN 0 VILLAGE
AND W'I' t
SPECIFY I mlng on
D. STREET ADDRESS 3507 Tall Pine Court ZIP 28409
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
03 /20 /1975
MONTH DAY YEAR
3. A. AGE 32
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Customer Sales & Service
B. TYPE OF INDUSTRY OR BUSINESS Atlantic Coast Tovota
5. PLACE OF BIRTH Belleville. New Jersev
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Richard B. Statile
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Patricia 0' Mallev
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. 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
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1%:'
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NAME (PRINT)
SIGNATURE~ ...
DOH.98 (0312006)
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
Lo
-.J
SUPPLEMENTAL FILE
FROM THE BRIDE
Stacej; Norma Hartlinir
DOLE CURR SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE St~tile
(OPTIONAL. SEE REVERSE) 0
D. SOCIAL SECURITY NUMBER 069-72-27 7
12. RESIDENCEA.NC B.New Hanover
(STATE) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~CIFY Wilmington
D. STREET ADDRESs3507 Tall Pine Court zIP28409
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 'tJ YES 0 NO
13. A. AGE27 3B. DATE OF BIRTH 05 )(2 ;1'980
MONTH DAY YEAR
14. EMPLOYMENT
A. 'USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS Alltel
15. PLACE OF BIRTHBronx, New York
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMEEdward Harold Hartlinq
'B. COUNTRY OF BIRTJJ S A
17. MOTHER
A. MAIDEN NAME Cindy Ann Carmosino
B. COUNTRY OF BIRTJJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
0'0' TH
(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) (CITYICOUNTY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
1ST
2ND
3RD
o
o
o
o
o
o
YEAR
10
29 2007
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNiY ~uTG~
c. LOCATION OF CEREMONY
(CHECK ONE AN~CIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY W MJ"; ~
STATE
SIGNATURE~