064
+
0>
co
LO
N
...... to-
~>- :>
lllZ ~
~_wu:
232~U.
~ ro~ c(
~3:~
In ~
a"CU
ll!C:::
W _
Cl=
<(
ii:
a:
:i32
II.
o
~
u
u:
~
W
U
W
a:
W
~
m
m
W
a:
o
o
<(
t
o
W
0-
m
w
en
z
w
0
:::::i
+
z' .
a:j!:~ W
~il= ~
a::O:~
Inffi~
:>-"g 0
~u u:
Cl
i~~ ~
ol:!
~g~ W
..We 0
~~Oll
OW
zg~
1. A. FUll NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Joseph Raymond Medina, III
FIRST MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COUNTY Dutchess
CITY/TOWN Wappinger
~~~~f: 1368 .
REGISTER 64
NUMBER
.J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Stacey Marie Travis
MIDDLE CURRENT SURNAME
1 1. A. FUll NAME
FIRST
0-
N
B. BIRni NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)113_52_1 058
D. SOCIAl SECURITY NUMBER
2. RESIDENCE A. NY B. OranQe
(STATE) (COUNTY)
C. CHECK ONE 0 ClTYo{] TOWN 0 VILLAGE
~~CIFY Wall kill
D. STREET ADDRESS 31 Old Mill Rd ZIP 12589
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES""O NO
3. A. AGE43 3B.DATEOFBiRTH 08 /09 /1966
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Medina
(OPTIONAL - SEE REVERSE~ 34-52-8253
D. SOCIAL SECURITY NUMBER
12. RESIDENCE l.JY B,orange
(STATE).L (COUNTY)
C. CHECK Qti,E. 0 CITY 1.J TOWN 0 VILLAGE
~~CIFYwallkill
D. STREET ADDRE~ 1 Uld Mill Kd ZIP 1 ZOl:l~
Ii
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES f6 NO
13. A. AGe46 3B. DATE OF BIRTH 02 J!7 )9 4
MONni DAY YEAR
w
~
4. EMPLOYMENT
A. USUAL OCCUPATION Sales Associate
B. TYPE OF INDUSTRY OR BUSINESS Retail
5. PLACE OF BIRTH Newburgh, Ny
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Joseph Raymond Medina Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Linda Lou Langlitz
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATIONS ales Associate
B. TYPE OF INDVllTFW OFJ BUSif'lFSsKetall
15. PLACE OF BIRTH valnalla, NY
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMEGeorge Joseph Travis
'B. COUNTRY OF BIRT.}) S A
17. MOTHER .
A. MAIDEN NAME Eileen Theresa Minter
B. COUNTRY OF B~ S A
18. NUMBER OF THIS MARRIAGE Z
rr.'
w
III
:IE
:>
z
Q
z
<(
ti
w
~
9. ~~~~~~~RM6'fm~~Tgus MARRIAGES WHICH ENDED BY 19. ~~~~~~~RM6'FR~If'E~gUS MARRIAGES WHICH ENDEO BY
DIV1RCE CIVIL AN5ULMENT OaTH DrORCE CIVIL A~ULMENT D'Q'TH
B. HOW DID LAST MARRIAGE END? (3) rJ DIVORCE (3) 0 ANNULMENT ~ 0 DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVO'(j5 (3) ~~NULMENT ~~ DEATH
C. DATE LAST MARRIAGE ENDED? 06 / 08 / 1 93' c. DATE LAST MARRIAGE ENDED? / / 19
MON11l.oo DAY YEAR MONTijo' DAY' . - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? Li 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) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE ~ONTH..,DAYnYEAR) SCITYICq\i,,"fTY.STAT~QUNTRY, IF NOT USA) SELF SPOUSE
06/08/1993 Goshen, Ny ~ 0 1ST u5/2.J/1 ::.194 Wnlte t"'lalnS, NY '6
o 0 2ND
o 0 3RD
o 0 4TH
and belief that the Information I provided Is true and
...
o
o
o
t exists
I
21. SIGNATURE OF GROO
US UR
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 onl for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) John C. Masters n
{SEAL SIGNATURE ~ DATE 06/15/2010 TIME MONTH YEAR
'-v-' MA~~GlOWcfdf~b h Rd, Wappingers Falls, NY 12590 03:37~~ 06 16 2010
STREET CITYITOWN STATE ZIP
~~R~~RT~~i ~~O~~N:::t~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. AY YEAR 00 RELIGIOUS 1w CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 90 OTHER, SPECIFY
MONTH
YEAR
08
14 2010
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY S)\ft.::._h'l S .
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF'M TOWN OF 0 VILLAGE OF
SPECIFY Wo..ff' r'f"....... r{/ L..,
STREET
3D. WITNESS TO CEREMONY .
NAME (PRINT)~~ to \ \ \ \ 0. mS
SIGNATURE