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COUNTY Dutchess
CITYfTOWN Wappinger
~~J~~c~1368 '
~~~~l~R164
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Derek Vernard Martin, Jr.
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Chelsea Kayte Hallett
MIDDLE CURRENT SURNAME
--.J
1 . A. FULL NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Martin
(OPTIONAL - SEE REVERSEl()67 -82-2283
D, SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STATE) oL (COUNTY)
C. CHECK ONE [J CITY L,J TOWN 0 VILLAGE
~~~CIFY PougnKeepsle
D. STREET ADDRESs21 SaddlerocK unve
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEV-96_76_7021
D, SOCIAL SECURITY NUMBERU
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY"b TOWN 0 VilLAGE
~~~CIFY PouQhkeepsie
D. STREET ADDRESS 21 Saddlerock Drive ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
08 /03 /1989
MONTH DAY YEAR
12603
ZIP
~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YE~..Q920
13. A. AGE 18 13B.DATE OF BIRTH 04 ))1 ~
MONTH DAY YEAR
3. A. AGE21
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION US Army
B. TYPE OF INDUSTRY OR BUSINESS Tanker
5. PLACE OF BIRTH Poughkeepsie, NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Derek Vernard Martin, Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Donna Marie Spears
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
14. EMPLOYMENT
A. USUAL OCCUPATION Cosmotologist
B. TYPE OF INDU~TR't OR BUSl~~S Cosmotology
15.PLACEOFBIRTH::;urfern, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Kenneth Robert Hallett
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Jeanne Maria Tedesco
B. COUNTRY OF BIRTHU S A
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI{fRCE CIVIL A~ULMENT
DEATH
o
D~TH
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
C. DATE LAST MARRIAGE ENDED?
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is
as to my right to enter into the m te.
--
o 0
o 0
o 0
o 0
pediment exists
21. SIGNATURE OF GROOM
22. SIGNATURE OF BRIO
USE cu
23, SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY .CLERK ~
This license authorizes the marriage in New Y State of the bride and groom named above by any person authorized by New York Domestic
- Relations-taw ~ 11 to perform marrlage-ceTemonies w~hin-New Yor1\State;-THIS UeENSE-V At1!TINNEw-YORK-S-TATE-ONl:Y:--
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY Cl-ERKC M t 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) JOn . as erson
{SEAL } SIGNATURE~
MAI~tl' M~ffle
"-v-I
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE 12/18/2010
ush Rd, Wappingers Falls, NY 12590
STATE ZIP
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
TIME
MONTH
YEAR
MONTH
YEAR
19
2010
06
16 2011
AM
01 :57 PM
12
CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~ JI1AA
C. LOCATION OF CEREMONY
(CHECK ONE ANDYECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY~'C€~ ~I\
NAME (PRINT)
SIGNATURE~
DOH-98 (09/2009)