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CITY/TOWN Wappinger
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
David Walter Valentine
MIDDLE CURRENT SURNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
.-J
1 , A. FULL NAME
FROM THE BRIDE
Christine Beth Valentine
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERE~uzzatto
C. SURNAME AFTER MARRIAGEValentine
(OPTIONAL. SEE REVERS~ 04-70-5190
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ~Y putchess
(STATE) _J-. (COUNTY)
C. CHECK ONE 0 CI, r ~ TOWN 0 VILLAGE
~~~cl~oughkeepsle
D. STREET ADORES? Maisie Court
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE!.
D. SOCIAL SECURITY NUMBER '135-80-2470
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 crr'/Yb TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
D. STREETADDRESS5 Maisie Court ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YE~D NO
06 /26 /1979
MONTH DAY YEAR
1 ~OU1
ZIP
>I
o YES 0 ND
~77
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AG~3 3B. DATE OF BIRTH 02 jJ2
MONTH DAY
3. A. AGE~n
3B. DATE OF BiRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Merchandise Handler
B. TYPE OF INDUSTRY OR BUSINESS Logistics
5. PLACE OF BIRTHWestwood. NJ
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Michael L Valentine
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Helen M. Galloway
B. COUNTRY OF BIRTH USA
B, NUMBER OF THIS MARF,lIAGE 1
14. EMPLOYMENT
A. USUAL OCCUPATIO~urse
B. TYPE OF INDUSTRY OR BUSINESsHealth Care
15, PLACE OF BIRT~mithtown, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMAlan Luzzatto
. B. COUNTRY OF BIRTM S A
17. MOTHER
A. MAIDEN NAMEMargaret Thompson
B. COUNTRY OF BIRTM S A
lB. NUMBER OF THIS MARRIAGE 2
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT D;(ITH
1 0 U
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) t:J DIVORCE (3) ~ ANNULMENT B& DEATH
C, DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 02 / 3 /20
MONTH DAY YEAR MONT~ DAY, . - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE (MONTH. DAY, YEAR) (CITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 02/23/2005 Dutchess County, New 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swe!lr/afflrm, dep.ose and say, th~t t~e bes 1 my knowledge and belief that the information I provided Is ue and that I declare that no egal impeKhdimenl-e~' ts
as to my right to enter Into the marriage e
21. SIGNATURE OF GROOM ~ 2 . SIGNATURE OF BRIDE
USE CURRE A
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME 04/12/2010
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State 01 the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11to 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
NAME (PRINT) ohn C. Mast
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
~
{ SEAL }
'-v-I
MONTH
YEAR
YEAR
TIME
MONTH
DATE 04/12/2010
in ers Falls NY 12590
CITYITOWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. AY YEAR D 0 RELIGIOUS
9 0 OTHER. SPECIFY
02:36~~ 04
13
2010
06
11 2010
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER,
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
2B. PLACE WHERE MARRIAGE OCCURRED
A, STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF J:!(TOWN OF 0 VILLAGE OF
SPECIFY~.s'Y F6f7K.JL-L.
.::rv~c r).
1}( CIVIL
29. OFFICIANT
NAME (PRINT)
$;
TITLE RiGHT 12E"/Et.erJP
DATE S-.. 2 2" /D
IV 'I I 2,+0/
STATE ZIP
31. WITNESS TO C~EMONY
"'''u~ '''CIIMT\ fC be { t
L v( '7:Z.. a tfo
SIGNATURE ~
MZ33REWAt.l-
STREET CITY/TOWN
30. WITNESS TO C~EMONY'~ L . -+ 1-0
NAU'" (PRINTI U~ to, n 1 ~ u.. 2- 2.. t::\