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COUNTY Dutchess
CITYrrOWN WappinQer
~~~:~c~ 1368 '
~~~~~R 23
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Matthew.John Pinto
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
~
Lo
SUPPLEMENTAL FILE
FROM THE BRIDE
Shawna Marie Davis
MIDDLE CURRENT SURNAME
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 C. SURNAME AFTER MARRIAGE Pi nto
D. S~:I~~~~~~U~~~RSE) 275-84-9887 D. s~~~~~~~~~U~~~~RSE) 281-90-2063
2. RESIDENCE A. New York B. Dutchess 12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY) (STATE) (COUNTY)
C. CHECK ONE 0 CITY g TOWN 0 VILLAGE C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W . AND W
SPECIFY appmger SPECIFY aooinaer
D. STREET ADDRESS 1 Sherwood Forest Aot. C ZIP 12590 D. STREET ADDRESS 1 Sherwod Forest Apt. C ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES I!'f' NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~i, NO
3. A. AGE ?A. 3B. DATE OF BIRTH On / 10 / 1982 13. A. AGE 25 3B. DATE OF BIRTH 08 /23 /1981
MONTH DAY YEAR MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Field Service Engineer
B. TYPE OF INDUSTRY OR BUSINESS I. B. M.
5. PLACE OF BIRTH Amherst. Ohio
(CITY, STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Dog Groomer
B. TYPE OF INDUSTRY OR BUSINESS Petsmart
15. PLACE OF BIRTH Erie County. Pennsylvania
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Bruce Davis
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Melissa Culp
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
6. FATHER
A. NAME I!=:aac Pinto
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary Ann Shreve
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
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEAJH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
w
en
z
w
o
:::::i
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, aep'ose and say, that 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 ~ state:/ /"::) "- \ A _. ~
21.SIGNATUREOFGROOM~ y~--.;-- d' L::,.~~- 22.SIGNATUREOFBRIDE~ ~
Jl:lE C~RENT NAM~ USE CURRENT NAME
23. ~~:~~~DO~~O~Oo~ c!~A~r:r~:t~ BEFORE~ ell.( JI IJ 7Yla.LL'L) DATE 04/02/2007
This license authorizes the marriage in New York State of 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.
o If checked, this license is to be used only for the urpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) John C. Mast
TIME MONTH YEAR MONTH
SEAL SIGNATURE" DATE 04/02/200
I..- ~ MAILj.N..~ AMD~I ~E~Pe AM
-v- ~u aalE appinQer Falls, NY 12590 12:1Q:>M 04
STREET CITYITOWN STATE ZIP
~~~~~R1l'~J IO~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS ~VIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
YEAR
2007
06
01 2007
03
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF
o VILLAGE OF
(
NAME (PRINT)
SIGNATURE"
e(ICV