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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~~r 1368
~~~':J~R 135
" I "" I E: vr I~E: vv ,un,,-
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Derrick John SullivanL Jr
MIDDLE CURReNT SURNAME
FIRST
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Christa Marie Rohr
MIDDLE CURRENT SURNAME
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Sullivan
(OPTIONAL. SEE REVERSEl125_58_2738
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Pleasant Valley
D STREET ADDREss20222 Emilie Lane
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEl1 07 58 4986
D. SOCIAL SECURITY NUMBER --
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ..tJ TOWN 0 VILLAGE
~~~CIFY Pleasant Valley
D STREET ADDRESS 20222 Emilie Lane ZIP 12569
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
09 /30 /1975
MONTH DAY YEAR
ZIP 12569
DYES '6 NO
)1"972
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 35 3B. DATE OF BIRTH 12 ~8
MONTH DAY
3. A. AGE ~?
38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Insurance Sales
B. TYPE OF INDUSTRY OR BUSINESS Insurance
5. PLACE OF BIRTH Y orktown, Ny
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Derrick John Sullivan. Sr
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Veronica Lynn Bordeaux
8. 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 Sales Manaqer
B. TYPE OF INDUSTRY OR BUSINESS Hospitality
15. PLACE OF BIRTH Poughkeepsie, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME William John Rohr, Sr.
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Carol Ann DiRenzo
B. COUNTRY OF BIRTHU S A
18. 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?
13) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
OATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
e est of my knowledge and belief that the Information I provided is true and that I declare that no legal impediment exists
C-R -- ~ o-h-
22. SIGNATURE OF BRIDE ~ _- USE CURR~NA~
DATE 09/10/2008
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23. SUBSCRIBED AND SWORN TO/AFFIRMED BEF E
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
} NAME (PRINT) John C. Masterson
{SEAL SIGNATURE ~ SJ..Q. r. ~ DATE 09/10/2008 TIME MONTH YEAR MONTH
'-v-I MAI~~Gi\RtdaTiltush Rd, Wappingers Falls, NY 12590 06:27~~ 09 11 2008 11 09 2008
STREET CITYrrOWN STATE ZIP
~~~R~:Rir~; 'o~O~~~N~~R~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 I9"1'iELiGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. ;""'"PM / tI 9 0 OTHER, SPECIFY
--r-; S' ~ {J TITL^
DAT~ If},
1 rft7 I~
STATE
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~~/
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
ECIFY /~
SIGNATURE~
DOH-98 (03/2006)