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1. A. FULL NAME
~ . "'" . ... "". .~"'1f1f . "". I.'
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mo~osore Olalekan Danmola
FIRST MIDDLE CURRENT SURNAME
( I HI:;' ~'-l1l.1C rUN \:) 1111 C U':'C VI'lL r J
COUNTY Dutchess
CITYfTOWN WappinQer
~~~:~; 1368
~~~I:~~R 165
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ruth Adjaloko
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE 0 a n mol a
(OPTIONAL. SEE REVERSE) 1 01-84-8339
D. SOCIAL SECURITY NUMBER
12 RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 1973 Route 9d
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY
(STATE)
C. CHECK ONE 0 CITY ..rJ
~~~CIFY Wappinger
D. STREET ADDRESS 1973 Route 90 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
10 /10 /1987
MONTH DAY YEAR
B. Dutchess
(COUNTY)
TOWN 0 VILLAGE
ZIP 12590
DYES tj NO
;f985
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 23 3B. DATE OF BIRTH 02 ~2
MONTH DAY
3. A AGE? 1
3B. DATE OF BIRTH
4. EMPLOYMENT
A USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS Unemploved
5. PLACE OF BIRTH Lagos. Nigeria
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A NAME T::tjlJdeen Adebowale Danmola
B. COUNTRY OF BIRTH Nigeria
7. MOTHER
A MAIDEN NAME Adesola Bintu Odufowora
B. COUNTRY OF BIRTH Nigeria
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
14. EMPLOYMENT
A. USUAL OCCUPATION Direct Care Professional
B. TYPE OF INDUSTRY OR BUSINESS Health Care
15. PLACE OF BIRTH Monrovia, Liberia
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Samuel A. Adialoko
'B. COUNTRY OF BIRTHGhana
17. MOTHER
A. MAIDEN NAME Emma E. Tandor
B. COUNTRY OF BIRTHGhana
1B. 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
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
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
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
w
U)
z
w
o
::i
1ST 0 0 1ST 0 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, that to the best of my knowledge and belief that the information I provided is true 'Y')d tt),at I de ar that no legal Impediment eXists
as to my right to enter into the ma:r1age state. " , '7L{ f)" , " 4,
21. SIGNATURE OF GROOM ~. fV) (),p "'-- 0, 22. SIGNATURE OF BRIDE ~ {.:Q
USE USE C
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New ork State of the bride and groom named above by any person authorized by New York Domestic
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
10/23/2008
DATE
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
'-.-I
NAME (PRINT)
DAY
YEAR
YEAR
MONTH
TIME
MONTH
DATE 10/23/200
in ers Falls NY 12590
ITYIT WN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TI E MO. DAY YEAR 0 0 RELIGIOUS 1 ~iVIL
/1 ~. AM 9 0 OTHER, SPECIFY
AM
12:37PM
10
24
2008
12
22 2008
STRE ET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY
,"h( ,~h ~
C. LOCATION OF CEREMONY
1M .~ (CHECK ONE AND SPECIFY)
,., \l V 'r!.. @ , , e ('
\ .;t /d-.. ~ It) Y 0 CITY OF TOWN OF 0 VILLAGE OF
. (I l SPECIFY
29. OFFICIANT
NAME (PRINT)
TITLE
7r> er/,,.'1I9/1/
NAME (PRINT)
SIGNATURE~