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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jac:k,Au31in M~
23. SUBSCRIBED AND SWORN TO BEFORE ME
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
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 purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ } NAME(PRINT) J~
. TI~
SEAL SIGNATURE ~ ' DATE 09/1417nn~
MAILING ADD RES AM
'-v-' ST~P Middlebush Rd, Wapp~f~II~, N'(TATP~Qn ZIP 05:48 PM
~~~R~~R:~~~ 10~0~~~NifEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS % CIVIL
DATE AND AT THE TIME AND A
PLACE INDICATED. M,. (J.j# 9 0 OTHER, SPECIFY
~~rJt~~W~~~ LJ R'/~8l-A"7 C" #'-,/ TITLE ~u..~ 7'i/.{, "P
DATE /Clj:<'9/t?r
/flY
COUN'Outchess
c'TYrrowr,lIVappingeF
DISTRICT v
NUMBE~368
REGISTE
NUMBER 115
1. A. FULL NAME
CURRENT SURNAME
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B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 108-52 3281
2. RESIDENCE ANewA~~rk B. D~SS
C. ~~6CK ONE 0 CITY ~ TOWN 0 VILLAGE
SPECIFY Fishkill
D STREET ADDRES!;4 1 T OWRview Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YESO'tl NO
JM-H /2i,y /1~
3 A. AGr49
4. EMPLOYMENT
3B. DATE OF BIRTH
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A. USUAL OCCUPATION Serviee Clerk
8. TYPE OF INDUSTRY OR BUSINEssHanaford's
5. PLACE OF BIRTtfi.~F 'tcn!Jk)
6. FATHER
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A. NAME John R. Martire
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary Tfinca
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
DEATH
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8. 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 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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21. SIGNATURE OF GROO~~
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STAI~ t"1L-C rcUMI::u:::;n
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
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11. A.
FROM THE BRIDE
FULL NAMEJes,~~ 510an MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE~art~. ~
(OPTIONAL - SEE REVER ::
o SOCIAL SECURITY NUM8ER 1 2-6218
12 RESIDENCE -N~TXert B.~~
C. CHECK ONE 0 CITY.tJ TOWN 0 VILLAGE
~~gcIFlf-isbkill
o STREET ADORES' 1 T ownview Drive zIP12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"1J NO
13. A. AG<:A2 13.8. DATE OF BIRTH "1 11 1~3
"'1 ~ONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATlor-erortur.tinn
B. TYPE OF INDUSTRY OR BUSINESsA R C Dutchess County
15. PLACE OF BIRT~lintnnNnrth Carolina
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMEJe'!llip- Frtwftm ~ln8n
8. COUNTRY OF BIRT" J ~ A
17. MOTHER
A. MAIDEN NAME Callie May ()wP-"'~
8. COUNTRY OF BIRT" J ~ A
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
8. 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
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
o
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1ST
2ND
3RD
o D
o 0
o 0
o 0
'mpediment exists
DATE 09/14/2005
by New York Domestic
MONTH
YEAR
MONTH
YEAR
09
15
2005
11
13 2005
28. PLACE WHERE MAP.RIAGE OCCURRED
A. STATE NEW YORK B. COUNTY G//~,.,
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
L LO 'Y J:)
SPECIFY