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COUNTY Dutchess
CITYfTOWN Wappinqer
~~~:~~ 1368 .
~~~I~J~R 31
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Scott Richard Serino
MIDDLE CURRENT SURNAME
r
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Cristina Irene Garrison
MIDDLE CURRENT SURNAME
.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Serino
(OPTIONAL - SEE REVERSE) 063 72 9490
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. New York B Dutchess
(STATE) (COUNlY)
C. CHECK ONE D CITY D TOWN ~ VILLAGE
~~~CIFY Wappinqers Falls
D. STREET ADDRESS 2534 South Avenue ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES D NO
13 A. AGE 25 3B. DATE OF BIRTH 03 /05 /1982
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 103 64 9636
D. SOCIAL SECURITY NUMBER --
2. RESIDENCEA. NAW York B. Dutchess
(STATE) (COUNlY)
C. CHECK ONE D CITY D TOWN IS1I' VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 2534 South Avenue
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE ?R 3B. DATE OF BIRTH
4. EMPLOYMENIT
A. USUAL OCCUPATION Repair Technician
B. TYPE OF INDUSTRY OR BUSINESS Medical
5. PLACE OF BIRTH Poughkeepsie. New York
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME PAtAr Richard Serino
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Diane Marie Stokes
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
ZIP 12590
r:f YES D NO
14. EMPLOYMENIT
A. USUAL OCCUPATION Loan Administration
B. TYPE OF INDUSTRY OR BUSINESS Banking
15. PLACE OF BIRTH Pouqhkeepsie, New York
(CllY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Neil Anthony Garrison
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Gail Ann Gudmundsen
B. COUNlTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL AI\jNULMENT
o 0
DEATH
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) (CllYICOUN'TY, 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!COUN'TY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST D D 1ST D D
2ND D D 2ND D D
3RD D D 3RD D D
~ D D ~ D D
I duly swear/affirm. dep.ose and say, th t to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the marn t 4 ' .
21. SIGNATURE OF GROOM. 22. SIGNATURE OF BRIDE. A l~o.. ~^.A~r-..c;.-C::::,
USE USE CU~
23. SUBSCRIBED AND SWORN TO! FFIRMED BEFORE ME 05/02/2007
SIGNATURE OF TOWN OR CITY CLERK~ DATE
This license authorizes the marriage in New rk State 0 the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 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. SOLlEMNIZATION PERIOD BEGINS
C. Masterson
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
'-v-I MAIL~B 'tOO~d
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
MONlTH
YEAR
TIME
MONlTH
DATE 05/02/200
appinger Falls, NY 12590
CllYrrOWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 D RELIGIOUS ~IVIL
9 D OTHER, SPECIFY
AM
05:3~M
05
03
2007
07
01 2007
28. PLACE WHERE MARRIAGE OCCURRE5-,. _ ~
A. STATE NEW YORK B. COUNTY ~f~4
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY 0
SPECIFY