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COUNTY [)ut~~
CITYrrowN Wappinoer
~~~~~cFi 1368
~B~~l~R 160
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
John E Merlino
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L D SUPPLEMENTAL FILE
1. A. FULL NAME
11. A. FULL NAME
FROM THE BRIDE
Marisa B. Walsh - Cramer
CURRENT SURNAME
FIRST
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Walsh
c. SURNAME AFTER MARRIAGE Merlino
(OPTIONAL - SEE REVERSE) Orv\ CQ9902
D. SOCIAL SECURITY NUMBER ::7U""UU'"
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 """OWN 0 VilLAGE
~~~CIFY East Fishkill
D STREET ADDRESS 27 Pleasant Hill Road
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) ^n~ A~5880
o. SOCIAL SECURITY NUMBER lJOO-&tO"
2 RESIDENCE A. NY B. [)utchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY [jllI\-OWN 0 VilLAGE
~~~CIFY East Fishkill
D STREET ADDRESS 27 Pleasant Hili Road
ZIP 12533
YES D~NO
/1967
YEAR
ZIP 12533
DYES D"""NO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE 36 13.B. DATE OF BIRTH 03 /10
MONTH DAY
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 51 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION School Administrator
B. TYPE OF INDUSTRY OR BUSINESS Wappinger Cntrl. Schools
5. PLACE OF BIRTH Bronx. New York
(CITY, STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Assistant Princi~
B. TYPE OF INDUSTRY OR BUSINESS Wappinger Cntrl. 8chls.
15. PLACE OF BIRTH Cortlandt. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Thomas Vincent Walsh
B. COUNTRY OF BIRTH USA
17. MOTHER
6. FATHER
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A. NAME John Merlino
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Angellf"lA , Atn
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 3
18. NUMBER OF THIS MARRIAGE
A. MAIDEN NAME Maria Theresa Pionataro
B. COUNTRY OF BIRTH USA
2
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9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT
2 001 0
B. HOW DID LAST MARRIAGE END? (3) 0 ~VORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 ~VORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 05/ 15/ 2003 C. DATE LAST MARRIAGE ENDED? 06/ 06 /
MONTH DAY YEAR MONTH .; DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 ~S 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 'i"ES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1105/1 Q80 Poughkeepsie. N Y 0 ~ 0 1 ST 06106I2OO2 PouahkeePSie. New York 0 0 ~
0511512003 poughkeepsie. NY 0 0 ~ 2ND 0 0
o 0 ~D 0 0
o 0 ~H 0 0
ledge a b"lief that the informatiDn I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ;-~ a.......- !J)~ - {!~11 /YJ1...I.A
. USE CURRENT NAME ./
23. SUBSCRIBED AND SWORN TO BEFORE ME 12/12l2OO3
SIGNATURE OF TOWN OR CITY CLERK ~ II DATE
This license authorizes the marriag 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 only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK. 25. A. SOLEMNIZATION PERIOD BEGINS
Glo a
DEATH
o
2082EATH
YEAR
1ST
2ND
3RD
4TH
I, being duly sworn, depDse and say, that tD e
as tD my right to enter into the marriage S
21. SIGNATURE OF GROOM ~
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{ SEAL }
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NAME (PRINT)
TIME
MONTH
YEAR
SIGNATURE ~
MAILI~A~i
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED. /~ :00 PM
~~r.?:~~9I~~i \.~;fJ rr;;t4. LL oS/.j TITLE /~r'~ (-
SIGNATURE ~ C AI\. ~c+ DATE / - (7 I -0 ~
MAILING ADDRES / Scl tiel-Ie v _/I,
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CITYfTOWN 1/--- U STAft ZIP
hrL {!ramer- N:~;~::~~;'T~~ ~e<<Mn(k;
SIGNATURE~ Jt:;lrJo.. (\ ~\horf\o.5"' c'('rj.,.fY\t.(
AM
03:25-v1
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTyb~
ot
o C3-F'rELlGIOUS
(J 1 9 0 OTHER, SPECIFY
10 CIVIL
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF G-'i7ILLAGE OF
SPECIFY Wt1f!if. ~~ 't-C1e!14/ t.fj