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ST ATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
stephen Patrick Martinez
FIRST MIDDLE . CURRENT SURNAME
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the in ormation I provided is tru~nd that I declare that no legal impediment exists
as to my right to enter into the marriage state. - ~
21. SIGNATURE OF GROOM ~ 22. NATURE OF BRIDE ~ _.A
E C RRE USE CUHH,;NT NAME
23 ~:;~~~~DO~N,.o~O~: ci;~Bg~~K ~E DATE n.m4J'JOO6
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 w York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to used only for the purpose of a second or subsequent ceremony.
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STREET Cli'YrTQWN TATE ZIP PM
~~~R~~RT~~~ IO~O'r~N:,z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1)i;l-"CIVIL
DATE AND AT THE TIME AND do
PLACE INDICATED. ~ 9 0 OTHER, SPECIFY
COUNTY Dutchess
CITYfTOWN WaDDinper
~~J:f~1368
~5~~J~R 25
1. A. FULL NAME
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE~1 ~9210
D. SOCIAL SECURITY.NUMBER Yil_~___
2 RESIDENCE A. New York B. n.~
(STATE) ~
C. CHECK ONE 0 CITY ~ TOWN 0 VILlLAGE
~~~CIFY FlShkill
D. STREET ADDRESS 7 Greenhill DrIve Ad.. 358 ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES~ NO
3. A. AGE25 3B. DATE OF BIRTH o..~ /77 /1aR1
MONTH DAY ~
4. EMPLOYMENT
A. USUAL OCCUPATION 011 Burner Service Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Valley 011
5. PLACE OF BIRTHcortIencl. New York
(CITY, STATEICOUNTRY IF NOT USA)
6. FATHER
A. NAME Hector Martinez
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME DorMn Marie En.aehtvn
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
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STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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11. A.
FROM THE BRIDE
FULL NAME AndrP.A MAri~ Be.
FIRST MIDD
CURRENT SURNAME
B. BJRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~~~~~~t~e~~M8dinez
D. SOCIAL SECURITY NUMBER 111.s:?-4945
12. RESIDENCE A~.xrrk' B.~
C. CHECK ONE 0 CITY '" TOWN 0 VILLAGE
~~~CIFYFlShkill
D. STREET ADDRESS/.. Greenhill Drive, Apt. ~5A ZIP125?4
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES~ NO
13. A. AGF21 13.B. DATE OF BIRTH nR .... ..-"R
-mNTH ~ DAY 1111 ~R
14. EMPLOYMENT
A. USUAL OCCUPATIONPharrnA~ TAr.hnir.iAn
B. TYPE OF INDUSTRY OR BUSINEss\NJII'Uart
15. PLACE OF BIRT~1~5R~XqN
16. FATHER
A. NAMe\NJIIter RmdN .Ir
B. COUNTRY OF BIRnU S A.
17. MOTHER
A. MAIDEN NAMEVidd R~ond
B. COUNTRY OF BIRntl S A
18. NUMBER OF THIS MARRIAGE 1
19. 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
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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29. OFFICIANT
NAME (PRINT)
28. PLACE WHERE MARRIAGE OCCURRED
STATE NEW YORK B. COUN~I ~ \U.
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY 6F~ TOWN OF 0 VILLAGE OF
SPECIFY t. /) ~ i ltje r
M~.,.h~e '-
~~~ .-'
ZIP
3'~'~~
,-.NAME (PRINT) ~ ~
SIGNATURE ~ .