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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
David Michael Rath
COUNTY Dutchess
CITYffOWN Wappinger
~~~:~c: 1368
~~~I:~~R 181
1 . A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
~
B. BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
{OPTIONAL - SEE REVERSEI093_62_0724
D SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D STREET ADDRESS 8 North Jackson Road ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
01 /06 /1965
MONTH DAY YEAR
3 A. AGE43
3B. DATE OF BIRTH
FROM THE BRIDE
D Lynn Hayward
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT V 0 I nick
c. SURNAME AFTER MARRIAGE Rath
(OPTIONAL - SEE REVERSEI058-56-927 3
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY B. Ulster
(STATE).L (COUNTY)
C. CHECK ONE 0 CITY [J TOWN 0 VILLAGE
~~~CIFY Hurley
D. STREET ADDRESs325 Glrcle Drive
11. A. FULL NAME
o YES "6 NO
)1'969
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 39 3B. DATE OF BIRTH 02 ,112
MONTH . DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Commercial Representative
B. TYPE OF INDUSTRY OR BUSINESS utIlity
15 PLACE OF BIRTH Poughkeepsie, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A NAME William Robert Volnick
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A MAIDEN NAME Joanne Marie Hall
B. COUNTRY OF BIRTH USA
16. NUMBER OF THIS MARRIAGE 4
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9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) t1 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 07 / 10 / 2008
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? &'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
07/10/2008 Pouohkeepsie, Ny rj' 0 1ST
o 0 2ND
o 0 3RD
o 4TH 0 0
belief that the information 1 provided is ~rue nd that I declare that no legal impedime~t exists
22. SIGNATURE OF BRIDE~ '_-LA -rf--11 D 111} (l~ (
1:JS~l1'" J
DATE 12/22/2008
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
Relations Law ~11 to pertorm 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
{ } NAME (PRINT) Jo C. Masterson
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE' 12/22/200
MAILING ADORES AM
'-v-I 20 Middl ush Rd, Wappinoers Falls, NY 12590 12:46PM 12
STREET CITYITOWN STATE ZIP
~~~R~~~RT~~~ IO~O~~~N~EE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND AM
PLACE INDICATED. PM 9 0 OTHER, SPECIFY
4. EMPLOYMENT
A. USUAL OCCUPATION Transmission System Operator
B. TYPE OF INDUSTRY OR BUSINESS Electric
5. PLACE OF BIRTH Beacon, Ny
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME John Martin Rath
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Barbara Josephine Aragona
B. COUNTRY OF BIRTH USA
a. NUMBER OF THIS MARRIAGE 2
DEATH
o
21. SIGNATURE OF GROOM ~
29. OFFICIANT
NAME (PRINT)
TITLE
SIGNATURE ~
MAILING ADDRESS
DATE
STREET
30. WITNESS TO CEREMONY
CITYfTOWN
NAME (PRINT)
SIGNATURE~
DOH-9a (03/2006)
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
3 0
B. HOW DID LAST MARRIAGE END? (3) ['j'DIVORCE (3) 0 ANNULMENT (210 DEATH
C. DATE LAST MARRIAGE ENDED?' 07 / 31 / 2008
MONTfL; DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES 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
07/31/2008 Kingston, Ny 0 6
07/11/2005 CatskIll, Ny 0 6
07/23/1993 Poughkeepsie, Ny 0 6
DEATH
o
by New York Domestic
MONTH
YEAR
23
2008
02
20 2009
2a. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~