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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
'amps ~ ~t1:::lrtin
MIDDLE CURRENT SURNAME
COUNTY nllkhp!=:!=:
CITYfTOWN \A/:::lrrinopr
~~J~~cJ 13f\f\
~5~g~R 1 R4
1, A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 199-60-8497
2. RESIDENCE A. 1'I~~Tt ork B. ~~l;.
C. CHECK ONE 0 CITY Iii!I' TOWN 0 VILlAGE
AND 1M '
SPECIFY vvapplnger
D. STREET ADDRESS 14 Kpt~h::lmtown RO::ln
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
ZIP 1 ?~90
DYES~NO
3B. DATE OF BIRTH
3. A. AGE 35
4. EMPLOYMENT
A. USUAL OCCUPATION La\AlYE'r
B. TYPE OF INDUSTRY OR BUSINESS Fin::ln~i:::ll ~prvi~p~ Form
5. PLACE OF BIRTH ~[rR~~U~~N~g[A~
6. FATHER
MO
A. NAME James Martin
B. COUNTRY OF BIRTH II 8 A
7. MOTHER
A. MAIDEN NAME Janet Cummings
B. COUNTRY OF BIRTH U S Ii
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
n
o
o
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
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
YEAR
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
IJtJtt
Ii -/ ~ .t!~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Trina I Pt=ltenallne
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. 81RTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE P::ltpn:::ulr!p
(OPTIONAl - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 ?? -nO-1197
12. RESIOENCEA. Npw Vork B. fJlJtr.hess
(ST A iti (COUNTY)
C. CHECK ONE 0 CITY [51" TOWN 0 VILLAGE
AND W .
SPECIFY Applnger
D. STREET ADORESS 14 Ketchamtown Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 36 13.B. DATE OF BIRTH Mg~H / ~i /j ~~~
14. EMPLOYMENT
A. USUAL OCCUPATION NlIn:;@.
B. TYPE OF INDUSTRY OR BUSINESS Hudson Valley Hospital
15. PLACE OF BIRTH RI Jrlinnton,. Vermont
(CITY. sTX'l'ElCOUNTRV IF NOT USA)
16. FATHER
A. NAME Ri~h:::\rn PAten::l\lne.
B. COUNTRY OF BIRTH l J S A
17. MOTHER
A. MAIDEN NAME Heather Bender
B. COUNTRY OF BIRTH Montrp::l1
18. NUMBER OF THIS MARRIAGE 7
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 0 0
B. HOW DID LAST MARRIAGE ENO? (3) cfDIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? ()~ / 1 R / 199n
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? [!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
09/18/1996 Saratoga, f\lE'\A1 Y orl<
D""
22. SIGNATURE OF BRIDE ~
1ST
2ND
3RD
4TH
I, being duly sworn, depose and
as to my right to enter into the
o 1ST
o 2ND
o 3RD
o 4TH
nd belief that the information I provided is true
"
23. SUBSCRIBED AND SWORN TO
SIGNATURE OF TOWN OR C DATE
This license authorize e marriage in New York St 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 urpDse of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL }
'-v-'
NAME (PRINT)
SIGNATURE ~
MAiliNG ADDRESS
ST
I CERTIFV THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TIME
MONTH
YEAR
ZIP
08:43 AM
PM
12
o 0 REliGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. CAU"f&T~C'W e'$S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ri TOWN OF 0 VILLAGE OF
SPECIFY \AI II Pp I /1/ '<'E..e
29. OFFICIANT
NAME (PRINT)
TITLE
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7.6
STATE
NAME (PRINT)
SIGNATURE ~