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NTY Dutchess
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CITYfTOW)I! Wappinger
DISTRICTl ;jots '
NUMBER
REGISTER ;jts
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mark Lloyd Gittens
MIDDLE CURRENT SURNAME
~I"'IC rlL.e nUMDcn
(THIS SPACE FOR STATE USE ONL Yi
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Labelle Ann Williams
~
1 ' A, FULL NAME
11, A, FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
B, BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)124-40-1179
D, SOCIAL SECURITY NUMBER
2, RESIDENCE A, NY B, Rockland
(STATE) .L (COUNTY)
C, CHECK ONL 0 CITY 0 TOWNU VILLAGE
~~~CIFY t-'omona
2U Urman ur
D, STREET ADDRESS ' ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~
3. A. AGE 46 3B, DATE OF BIRTH 07 / 1
MONTH DAY
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEl120-66-2245
D, SOCIAL SE,PV/l1]Y NUMBER
NY Dutchess
12, RESIDENCE A, B,
(STATE).L (COUNTY)
C, CHECK O~ nO CITY D TOWN 0 VILLAGE
AND t-'oug lKeepsle
SPECIFY 5 10 Maloney Rd 12603
D, STREET ADDRESS ZIP V
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORAT1D VILLAGE? ?9 0 YE~JJ.gO
13, A, AGE43 3B, DATE OF BIRTH 1 C ~
MONTH DAY YEAR
'I Utlf 0
YES [J NO
/1962
YEAR
4. EMPLOYMENT
14, EMPLOYMENT .
A. USUAL OCCUPATION Social Worker
::;oclal vvork
B, TYPE OF INDU,prRY OR BjJSINESS
l:irenaaa
15. PLACE OF BIRTH
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Lee Paul
. Grenada
B. COUNTRY OF BIRTH
A. USUAL OCCUPATION Police Officer
B. TYPE OF INDUW'RY OR BlJl'iINESS Law Enforcement
5. PLACE OF BIRTH l:Sronx, New York
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Lloyd Gittens
B. COUNTRY OF BIRTH Panama
7. MOTHER
A. MAIDEN NAME Mercedes Louder
B. COUNTRY OF BIRTH USA
2
8. NUMBER OF THIS MARRIAGE
17. MOTHER Alb rtha Williams
A. MAIDEN NAME e
Grenada
B. COUNTRY OF BIRTH 2
18. NUMBER OF THIS MARRIAGE
w
en
z
w
()
:::i
9, PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~RCE CIVIL AN5ULMENT DEeTH DI{ORCE CIVIL A"B'ULMENT
~ ~
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT 2~B1DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVOR~b (3) c:t~NULMENT 1 g~~ DEATH
C. DATE LAST MARRIAGE ENDED? 09 / 07 / C. DATE LAST MARRIAGE ENDED? / /
MONT~ DAY YEAR MONT~ 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) (CITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOoUSE 1 ST ~~NJt!9Dp..19Y~l\f!) Ne(CwITY/f9UoNTI'rk,ST.NyE/COUNTRY. IF NOT USA) So ELF SPO~SE
1ST 09/07/2001 New York, NY 6 1 U/L 11 ~tl Y N 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, depose and say, t e best of.JJ'\'y 0 ledge and belief that the information I provided is true and that declare that no legal impediment exists
as to my right to enter into the marriage stat VI .
21. SIGNATURE OF GROOM~ L ~. i .-/'"
U U
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 by New York Domestic
Relations Law ~11 to perfonn 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 CI C ERK 25. A. SOLEMNIZATION PERIOD BEGINS
n
D~TH
USE CURRENT NAME
05/13/2009
DATE
MONTH
YEAR
YEAR
TIME
MONTH
DATE 05/13/2009
a Is, NY 12590
2009
07
12 2009
AM 05
12:35PM
14
ZIP
~
28. PLACE WHERE MARRIAGE OCCU~
A. STATE NEW YORK B. COUN'P' D~~.~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF )(TOWN OF 0 VILLAGE OF
SPECIFY 0~,o) /J..3 f7 r
JJe I!.ns:. t:;
~
J{'
ZIP
31. WITNESS TO CTIMOt'lY
NAME (PRINT) ~y 0. A
SIGNATURE~ G D ~o
. BR..O uJ 1'\
Q,l~~