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1. A. FUll NAME
STATE OF ,NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael J.
FIRST MIDDLE
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
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L 0 SUPPLEMENTAL FILE
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FROM THE BRIDE
samantha K.
FIRST MIDDLE
Lamberg
CURRENT SURNAME
Dore
CURRENT SURNAME
11. A. FULL NAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B Dutchess
(STATE) . (COUNTY)
C. CHECK ONE [] CITY Xl TOWN [] VILLAGE
AND
SPECIFY Wappinger
D. STREET ADDRESS 240 Chelsea Road
B BIRTH NAME, IF DIFFERENT
Lamberg
063-56-9935
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2 RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE C CITY ~ TOWN [] VilLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 240 Chelsea Road
053-68-2925
12590
ZIP 12590
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? [] YES ~ NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? [] YES)tJ NO
3. A.AGE 30 3B.DATEOFBIRTH July /28 /1969 13. A. AGE 25 13.B.DATEOFBIRTH Feb. /17 /1975
MONTH DAY YEAR MONTH DAY YEAR
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Assistant Designer
B. TYPE OF INDUSTRY OR BUSINESS Regal Bag
15. PLACE OF BIRTH Smithtown, New York
(CITY. STATEiCOUNTRY IF NOT USA)
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A. USUAL OCCUPATION Sales
B. TYPE OF INDUSTRY OR BUSINESS Self-employed
5. PLACE OF BIRTH Yonkers. New York
,CITY. STATElCOUNTRY IF NOT USA)
16. FATlHER
A. NAME
B. COUNTRY OF BIRTIH
17. MOTHER
Arnold Lamberg
USA
6. FATHER
A. NAME Cornelius Dore
B. COUNTRY OF BIRTH USA
7. MOTHER
Marsha Lind
USA
18. NUMBER OF THIS MARRIAGE Fir s t
A. MAIDEN NAME
Jean Coxen
A. MAIDEN NAME
B. COUNTRY OF BIRTH
8. NUMBER OF THIS MARRIAGE
USA
First
B. COUNTRY OF BIRTH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) [] ANNULMENT
/ /
(2) [] DEATH
B. HOW DID LAST MARRIAGE END? (3) C DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) [] ANNULMENT
/ /
(2) = DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? eYES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) '.CITY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) ,CITY. STATE-COUNTRY. IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say. that t
as to my right to enter into the marriage
21. SIGNATURE OF GROOM.
o [] 1ST
,~ 2ND
'-' 3RD
[] 0 4TH
e and belief that the information I provided i
c
,
23.
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This license authorizes the marriage in New York St e 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 pu se of a second or subsequent ceremony.
~ 24 TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRIN~Elaine H~nowden, Town Clerk
{SEAL SIGNATURE 1'J1I1l\ \ 'JV..~~-t.L DATE 4/20/00 TIME MONTIH DAY YEAR
MAILING ADORE 5 ' AM
'-.t-i ST~ Box 24 Wa in er~ Falls, NY 12590 P 12:30PM 4
~~~R~~~Ri~~~ IO~O'J.~N~Z:~ 26. SOLEMNIZATION OCCURRED
SONS NAMED ABOVE ON THE TI E MO. DAY Y R
DATE AND AT THE TIME AND
PLACE INDICATED.
6
19
00
25. B. SOLEMNIZATION PERIOO
ENDS AT MIDNIGHT ON:
MONTIH
DAY
YEAR
21
00
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28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEWYORK B. COUNTY~
C. LOCATION OF CEREMONY
(CHECK ONE ANrt SPECIFY)
"CITY OF " TOWN OF [] VILLAGE OF
29. OFFICIANT
NAME (PRINT)
SPECIFY
NAME (PRINT)
SIGNATURE.
.DQH088 (11l18)
NAME (PRINT)
SIGNATURE ..