081
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
David J. PaalIIi
J COUNTY Dutchess
C;TYfTOWN vveppngef
DISTRICT 1~
NUMBER
REGISTER 81
NUMBER
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23. SUBSCRIBED AND SWORN TO BE E ME
SIGNATURE OF TOWN OR CITY CLERK"
This license authorizes the marriage in New York S
Relations Law ~11 to perform marriage ceremonies withi ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the pu ose of a second or subsequent ceremony.
~ 24. TOWN OR CITY jl.I.ER'S 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) '=iIOIi& J. ManIe
{ ~ ~
SEAL SIGNATURE"- e TE
MAIL~ebush R Falls, NY 12590 11:S3M 06
'-.,.-I STR A ZI PM
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY ~
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE 0 0 RELIGIOUS 1 IVIL
DATE AND AT THE TIME AND
PLACE IN 9 0 OTHER, SPECIFY
1. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
Il. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 0'5l- 72-1 f1i1
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. DutcheBB
(STATE)'; (COUNTY)
C. ~~~CKONE p._Q-EI1Y_92<?WN 0 VILLAGE
SPECIFY gugr1K8e1Be
D. STREET ADDRESS er.l1 5neme R080 LOt 31 ZIP 1~
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 ~O
08/ 28 / 197
MONTji DAY YEAR
3. A. AGE
27
3B. DATE OF BIRTH
EMPLOYMENT
A. USUAL OCCUPATION Prep Manager
B. TYPE OF INDUSTllt S>~ BUSINE~~ _~rt ACUra
PLACE OF BIRTH tsellcon, NeW York
(CITY, STATEICOUNTRY IF NOT USA)
FATHER
A. NAME
Marco John PBoIHli
USA
B. COUNTRY OF BIRTH
MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
DenIse Celllne GeNtIIs
USA
8. NUMBER OF THIS MARRIAGE ,
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORlf CIVIL ANNUbMENT
DEAl
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
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
o
o
o
21. SIGNATURE OF GROOM"
29. OFFICIANT
NAME (PRINT)
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL V)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
L.eslianne Martin
~
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
Il. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE PaoIiIIi
(OPT1ONAL - SEE REVERSE) 054-7409428
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. DutcheIa
(STATE).; (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~CIFY PoUghk8epBie
D. STREET ADDRESS 521 5ne1fe R080 ... 31 ZIP 12t503
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 ~O
08 / 29 /1979
MONTH DAY YEAR
13. A. AGE 23
14. EMPLOYMENT
A. USUAL OCCUPATION
13.B. DATE OF BIRTH
Un - Empoyed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Quantico, Vlrdnll
(CITY. STATElCOUNTRY IF NOT USA)
16. FATHER
A. NAME limalhy Scatt Martin
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Marianne Jesneu
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVO&CE CIVIL ANNUbMENT
DEATH
o
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
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
York Domestic
YEAR
28. PLACE WHERE MARRIAGE OCCU~ _ .... ~
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY
(CHECK ONE AND SP CIFY)
o CITY OF
o VILLAGE OF
,t~.tL
ZIP
31. WITNESS TO CEREMONY
NAME. (PRINT)--=
SIGNATURE ..
~~