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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael Martino
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
COUNTY Dutchess
CITYfTOV;: wappinger
~:JJ~~~ 358
REGISTER 101
NUMBER
L 0 SUPPLEMENTAL FILE
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Pai Ki~~'1t~~Us
11. A. FULL NAME ge
FIRST MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
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B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), MIMiiI
C. SURNAME AFTER MARRIAGE ~21-
(OPTIONAL - SEE REVERSE)UUD'" ..-: ....
D. SOCIAL SE~'. DutdlCaD
12. RESIDENCE A. (STATE)'; B. (COUNTY)
C. X~6CK Oelintall CITY 0 TOWN 0 VILLAGE
SPECIFY 27 Lauren Lane
D. STREET ADDRESS ZIP
E. IS RE~CE WITHIN LIMITS OF CITY OR INCORPORAlf4'ILLAGE?1~ 0
13. A. AGE 13.B. DATE OF BIRTH L
MONTH DAY
14. EMPLOYMENT Oftice Manager
A. USUAL OCCUPATION l..eistIre Tech
B. TYPE OF INDLWJ1t~e t 1_. ..'01....,
.rUUW'l~ , Iv... , "
15. PLACE OF BIRTH
(CITY, STATElCOUNTRY IF NOT USA)
16. FATHER Wlliem Eugene Purham..
A. NAME USA
B. COUNTRY OF BIRTH
~NO
YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEl111->>2853
D. SOCIAL SE~~ER.
2. RESIDENCE A. ark B. DutCheSS
(STATE)., (COUNTY)
C. CHECKON~._.I.CLCITY 0 TOWN 0 VILLAGE
~~~CIFY UlnIDn
D. STREET ADDRESS 'Z1 Lauren 18ne
12580
12580
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YEAR
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ZIP
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E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED ~GE? ....JJ
3. A. AGE 36 3B. DATE OF BIRTH ~
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Installs SWimming Pools
B. TYPE OF INDU~RY ~I'" ~o.1c:Ernpoyed
5. PLACE OF BIRTH on ·
(CITY, STATElCOUNTRY IF NOT USA)
6. FATHER rti
A NAME Pasc,aale Me no
B: COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Diane Falcone
B. COUNTRY OF BIRTH U 6t
8. NUMBER OF THIS MARRIAGE
17. MOTHER MargaretAI'm Embree
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH 1
18. NUMBER OF THIS MARRIAGE
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI'(fRCE CIVIL A'lJ!LMENT
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVO~CE CIVIL ANtyLMENT
.;
B. HOW DID LAST MARRIAGE END? (3) 0 DIVOR'f2 (3) DO!ULMENT 2d DEATH
C. DATE LAST MARRIAGE ENDED? .--10 / /
MONT... 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
(~~ P8U0ftl(ijflfl:'I'QYT USA) SE~ SPOUSE
1ST . ...... ... ... . .... ......., ... . 0 0 1ST
~ 0 0 ~
~ 0 0 ~
~ 0 0 ~
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provide
as to my right to enter into the marriageolilate.
21. SIGNATURE OF GROOM ~
DVH
Deu-H
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
YEAR
MONTH DAY
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 0
o 0
o 0
o 0
legal impediment exists
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York St the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within ew 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.
{ ~ } ::~~;~NI~~ CI'C~. MEasterson 25. A. SOLEMNIZATION PERIOD BEGINS
SEA ' _......... :1f.2Uob TIME MONTH DAY YEAR MONTH
L SIGNATURE ~ ~ .:==:::::::.. V ~~~
'-v-I MA2fJ' ppnger Falls, NY 12590 10
STREET STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
l~VIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY .DI."J~~S
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~TY OF
SPECIFY
NAME (PRINT)
SIGNATURE~
DOH-98 (11198)
NAME (PRINT)
SIGNATURE ~