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COUNTY Dutchess
CITYITOWN Wappinger
~~J~:f~ 1368 .
~5~~~~R 81
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mi~h~t6~/~tp.rhp.n MR~lM~~NAME
I
STATE FlL.E NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
J~I~f Lisa US~U~RENT SURNAME
11. A. FULL NAME
FIRST
1. A. FULL NAME
FIRST
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N
B. BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE M::l rti n 0
(OPTIONAL _ SEE REVERSE) (OPTIONAL - SEE REVERSE)
o SOCIALSECURITYNUMBER 108-68-6363 D. SOCIAL SECURITY NUMBER 070-72-2647
2. RESIDENCEA. Np.w York B nlltr.hp.!=:!=: 12. RESIDENCEA. New York B Dutchess
(STATE) (COUNTY) (STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Fishkill ~~~CIFY Fishkill
D. STREET ADDRESS 1006 Pondview Loop ZIP 12590 D. STREET ADDRESS 1006 Pondview Loop ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r5 NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d ND
3. A. AGE ?7 3B. DATE OF BIRTH 11 / 16 / 1978 13. A AGE 27 3B. DATE OF BIRTH 04 /06 /1'979
MONTH DAY YEAR MONTH DAY YEAR
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4. EMPLOYMENT
A. USUAL OCCUPATION Service Manager
B. TYPE OF INDUSTRY OR BUSINESS Cintas Corp,
5. PLACEOFBIRTH Binahamton. New York
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Eugene Anthony Martino
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary Colleen Egan
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
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Putnam Valley Schl. Dist.
15. PLACE OF BIRTH New Hartford, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard M. Usvk
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Debra J. O'Hara
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
(31 0 ANNULMENT (2) 0 DEATH
/ /
. - YEAR
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?
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. 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) (CITYICOUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
al impediment exists
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o
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, ~t t 'the
as to my right to enter into th~J)1J~ S te.
21. SIGNATURE OF GROOM"
23. SUBSCRIBED AND SWORN TO/AFFIRMED
SIGNATURE OF TOWN OR CITY CLERK ~
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 onl for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITJ8fi'tf C. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)
06/26/200 TIME MONTH YEAR MONTH DAY YEAR
SEAL SIGNATURE ~' DATE
'-.t-I MAI~'WRtfd appinger Falls, NY 12590 12:2~~ 06 27 2006 08 25 2006
ZIP
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
CITYITOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
STATE
27. TYPE OF CEREMONY
0)3- RELIGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY ~o/-A~n:>J
10 CIVIL
D/
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) -1((]r ;
SIGNATURE~ K0" l'
n. Cie,lok
r1. ('_~ 1.rL.l? .)