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COUNTY Dutchess
CITYfTOWN Wappinger
~~J:~c~ 1368 .
~5~~~~R 112
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Arl~~o~::Iymnnrl M~IJrittRNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Malinda Ann Pollack
MIDDLE CURRENT SURNAME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 122-72-4334
2. RESIDENCE A. NY B. nlltr:hA!=:!=:
iSr ATE) (COUNTY)
C. CHECK ONE it'! CITY 0 TOWN 0 VILLAGE
AND P hk .
SPECIFY 0119 eepsle
D. STREET ADDRESS 183 Red Cardinal Court ZIP 12603
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VilLAGE? r1 YES 0 NO
3. A. AGE 28 3B. DATE OF BIRTH MON~4 / oJn / y~~R?
4. EMPLOYMENT
A. USUAL OCCUPATION liP!=;
B. TYPE OF INDUSTRY OR BUSINESS UPS
5. PLACE OF BIRTH Pnuahkeensie, Nv
(CITY, S'l'i(TE 1 COUN'fRY IF NOT uSA)
6. FATHER
A. NAME Robert. R MArritt
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Judith D O'Leary
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
n O'
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE MArritt
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 135-78-2728
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VilLAGE
AND P hk .
SPECIFY oug eepsle
D. STREET ADDRESS 183 Red Cardinal Court ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? i!l' YES 0 NO
13. A. AGE ?fi 13B.DATE OF BIRTH 08 /05 /1984
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Patient Service Rep.
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH Voorhees Twp.. New Jersey
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard John Pollack
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Cheryl Lynn Lippincott
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to
as to my right to enter into the marriage
21. SIGNATURE OF GROOM ~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
he best of my knowledge and belief that the information I provided is true and that I declare that no
o
o
o
USE CUR
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
n
DATE 08/26/2010
by New York Domestic
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
"-v-' MAIL2B 'refl
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TIME
MONTH
YEAR
MONTH
YEAR
DATE 08/26/201
ers Falls NY 12590
STATE . ZIP
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
AM
02:04>M
10
25 2010
08
27
2010
28. PLACE WHERE MARRIAGE OCCURRED
A, STATE NEW YORK B. COUNTY l? ",+J-fJJ
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF JiI TOWN OF 0 VILLAGE OF
SPECIFY WtA If; V;-e v
tA(1' CIVIL
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH.98 (0912009)
NAME (PRINT)
SIGNATURE~