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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
ScoUo~ward Milh~ SURNAME
COUNTY Dlltchess
CITYrrOWN WappingF!r
~~~:~c; 1 368 .
~5~I~J~R 76
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 115-70-Q!=l?Q
2. RESIDENCEA. NYsTATE) B. q~ss
C. CHECK ONE 0 CITY.,jlJ TOWN 0 VILLAGE
~~~CIFY Fishkill
D STREET ADDRESS 1!=l A V:::In Cnrtl:::lnd Circle ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ItJ NO
Mol~ /~? / J&ZO-
3. A. AGE 39
4. EMPLOYMENT
A. USUAL OCCUPATION IT
3B. DATE OF BIRTH
B. TYPE OF INDUSTRY OR BUSINESS Infnrm~tinn TF!r.hnology
5. PLACE OF BIRTH North TClrrutnwn N~
(CITY, STATE / COUrtrRY IF Not USAf
6. FATHER
A. NAME Thomas Joseph Milholm
B. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A. MAIDEN NAME Ma1lreen ThF!rF!~~ Mr.GlJire
B. COUNTRY OF BIRTH II ~ A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
o
DEATH
n
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
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL YI
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Amanda Elizabeth Torres
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Milholm
(OPTIONAL. SEE REVERSEb 16
D. SOCIAL SECURITY NUMBER 99-70-95
12. RESIDENCE ANY BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDREss15 A Van Cortland Circle
ZIP 12508
o YES'6 NO
;(982
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE ?7 13BDATE OF BIRTH 10 ...28
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Administrative
B. TYPE OF INDUSTRY OR BUSINESS Internet
15. PLACE OF BIRTH White Plains, Nv
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Joe Anthony Torres
'B. COUNTRY OF BIRT~uerto Rico
17. MOTHER
A. MAIDEN NAME Laurie Neidich
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. 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 (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 ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1 ST 0 0 1 ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm. depose and say, that to the b st of my knowledge and belief that the information I provided is true and t
as to my right to enter into the m~e stllte.
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF BRIDE~
o 0
o 0
o 0
o 0
re that no legal impediment exists
USE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
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
W
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{ SEAL }
'-.t-I
NAME (PRINT)
E
07/01/2010
DATE
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
DATE 07/01/2010
in ers Falls NY 12590
ITYIT WN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 M RELIGIOUS
9 0 OTHER, SPECIFY
STR EET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
AM
; ~ og 08 z.,,,,
~~J>tf~~~~T MAKsittl Le.swoVSKiy
SIGNATURE~ ~ ~
MAILING ADD~~ (j , · J.
~E! ~~ ~TYrrog~S-I~' ~
30. WITNESS T~CERE.NY ~ ..
NAME (PRINT) ~ II" ...
SIGNATURE~ :LA rJ c.... K I rJ IV
DOH-98 (09/2009)
AM
02: 14PM
07
02
2010
08
30 2010
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY
wesra~)#
TITLE ~veRQ.Ald
DATE ~ /8/ Z,Q/O
1/rA' ' o.r~~
C. LOCATION OF CEREMONY
(CHECK ONE Ar-p SPECIFY)
o CITY OF . TOWN OF 0 VILLAGE OF
SPECIFY r'o~K~tJ
......-;-
ot~
NAME (PRINT)
SIGNATURE~