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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Raymond Michael Valentin
MIDDLE CURRENT SURNAME
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, depose and say that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the mge_state. v\. .~ I ~ hI Jm In IAn I
21.SIGNATUREOFGROOM~ .SIGNATUREOFBRIDE~~\ !C UU,..l 111\ ~~
USE CUR USE CUIIRENT NAME 06/07/201 0
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage 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
n
~
{ } NAME (PRINT) .
SEAL SIGNATURE~ DATE 06/07/2010
'-v-I MA~5G I tush Rd, Wa pingers Falls, NY 12590
STREET CITYITOWN . . STATE ZIP
~~~R~~RT~~J lo~Oi~~N~EE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~RELIGIOUS
DATE AND AT THE TIME AND 2.. AM / .,
PLACE INDICATED. J PM fc:) I L. I 0 9 0 OTHER, SPECIFY
~~~~:m ~B. ~~,..,; . rrn.,-L.J!ol.c P,:.....
SIGNATURE~~ B.__-------o DATE L/I1./'O
MAILING ADDRESS Gl
'c~ .)~~j(~(>" S~. BtJ)/ L nshJt;II
STREET CITY/TOWN
30. WITNESS TO CEREMON
COUNTY Dutchess
CITY/TOWN Wappinger
~~J:~c~1368 .
~5~~J~R 58
1. A. FULL NAME
FIRST
<L
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEb67 _ 70-1384
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NH B. Grafton
(STATE) (COUNTY)
C. CHECK ONE 0 CITYOf(] TOWN 0 VILLAGE
~~CIFY Rumney
D. STREETADDRESS231 East Rumney Rd ZIP 03266
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VilLAGE? 0 YES"D NO
07 /21 /1984
DAY YEAR
3. A. AGE25
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Catering Maniger
B. TYPE OF INDUSTRY OR BUSINESS Hospitality
5. PLACE OF BIRTH Poughkeepsie, Ny
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Rafael Valentin
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Patricia Anne Borden
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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 ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY. STATEICOUNTRY. IF NOT USA) SELF SPOUSE
a:
w
Ol
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NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
I
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Nicolle Marie Tomlins
--1
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Valentin
(OPTIONAL - SEE REVERSEn63 74 2217
D. SOCIAL SECURITY NUMBER V
12. RESIDENCEA~H BGrafton
(STATE).L. (COUNTY)
C. CHECK qtJ,E 0 CITY -U TOWN 0 VILLAGE
~~~CI~umney
D. STREETADDREsf;:Sl cast Kumney KC
03266
ZIP "
o YWEr
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VILLAGE?
13. A. AG~2 3B. DATE OF BIRTH 11 )'6
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Teller
B. TYPE OF IND~TRY Of! /lUSINESS.l::SanKmg
15. PLACE OF BIRTHt-'ougnKeepsle, Ny
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMEKenneth Francis Tomlins III
. B. COUNTRY OF BIRTJJ ~ A
17. MOTHER .
A. MAIDEN NAMEJoanne Mane Monte
B. COUNTRY OF B;JJ S A
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DffoRCE CIVIL A~ULMENT
D10'TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (CITYICOUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
YEAR
08
06 2010
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY) "l t (, h, ~ S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF [!(TOWN OF 0 VILLAGE OF
SPECIFY
#=;~~K:IJ
Sr.;:;/E
NAME (PRINT)
SIGNATURE~