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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mark Anthony Martin
COUNTY Dutchess
CITYiTOWN wappinger
DISTRICT 1368
NUMBER'
REGISTER 99
NUMBER
1 A FULL NAME
FIRST
MIOOLE
CURRENT SURNAME
8 BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSElQ67 -60-7998
o SOCIAL SECURITY NUMBER
2. RESIDENCE A. New Yark B Dutchess
(STATE)'; (COUNTY)
C. CHECK ONWa Q CITY 0 TOWN 0 VILLAGE
~~~CIFY ppenger
o STREET ADDRESS 7 Maurice Dl'IVe
12590
ZIP
.,
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES f-~
3. A AGE 40 38 DATE OF BIRTH 05 /14 / ~5
MONTH DAY YEAR
4. EMPLOYMENT
A USUAL OCCUPATION H. V. A. C. Mechanic
5. :LA::~~:I:~Uf:IOIth f8~ ~~~ed
(CITY, STATElCOUNTRY IF NOT USA)
6. FATHER
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A. NAME Wolfgang Marlin
B. COUNTRY OF BIRTH Germany
7. MOTHER
A MAIDEN NAME Jean PattIson
B. COUNTRY OF BIRTH Scotland
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVcaCE CIVIL ANrfLMENT
DE6H
8 HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
MONTH OA Y 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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
11. A.
L 0 SUPPLEMENTAL FILE
FROM THE BBIDE
Amy Anne Wpovmoulh
FULL NAME ....1
FIRST MIOOLE
CURRENT SURNAME
B BIRTH NAME (MAIDEN NAME), U:Mtr
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)UU2-62-~575
D. SOCIAL SE~ITY NIl1BEI1c uutcness
12. RESIDENCE A. ew 0 B
(STATE)" (COUNTY)
C. ~~5CK ~pPhaif 0 TOWN 0 VILLAGE
SPECIFY 7 1l..1 . ..... I
mllUnce ..,r Vel
D. STREET ADDRESS
12590
ZIP ."
~NO
YEAR
E. IS RE~CE WITHIN LIMITS OF CITY OR INCORPORAYiJILLAGE?",::; 0
13. A. AGE 13.8 DATE OF BIRTH ~
MONTH OA Y
14. EMPLOYMENT M
A. USUAL OCCUPATION ana~. C. R.
B, TYPE OF IND~BY_QR_~~E~. U-hI
15, PLACE OF BIRTH I"(~. Nf!1N namP5 re
(CITY, STATElCOUNTRY IF NOT USA)
16. FATHER DB .e1 M rk\A'-....outh
A. NAME m 8 ...~,....
8. COUNTRY OF BIRTHU S A
17, MOTHER R Jea DavIs
A. MAIDEN NAME oxane n
8. COUNTRY OF BIRTHU S ~
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI'(fRCE CIVIL A"tiULMENT
D"l)TH
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
13) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH OA Y YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, OAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, tha
as to my right to enter into the marria at
~
o 0 1ST 0 0
o 0 2ND 0 0
o 0 mD 0 0
o 0 4TH D 0
knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within Ne 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 CI 'h''C. M 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
21. SIGNATURE OF GROOM ~
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{ SEAL }
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SIGNATURE ~
MA2OlOIi
22. IGNATURE OF BRIDE ~
TIME
MONTH
YEAR
AM 08
12:27 PM
27
ZIP
YEAR
STATE
27. TYPE OF CEREMONY
o P<l RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
CITY !TOWN
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
q- 11-0.:r
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TITLE
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNTY 1)Ac.1 fS$'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF i;J TOWN OF 0
SPECIFY lL)~~')(\; 11I8' f t"
,,,
VILLAGE OF