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COUNTY Dutchess
CITYfTOWN WappinQer
~~~:~CRT 1368 .
~5~1~~~R 1 03
~ I '"' I r::. vr ."'1:: YY , un"
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
George Omondi
MIDDLE CURRENT SURNAME
(THIS SPACE FOR STA TE USE ONL Y)
.J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Danielle Marie Patterson
MIDDLE CURRENT SURNAME
1. A. FULL NAME
11. A. FUll NAME
FIRST
FIRST
0..
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Omondi
(OPTIONAL. SEE REVERSE)073_64_4755
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESl97 Old Route 9, Unit B 1
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)126 86 4150
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY"l"J TOWN 0 VILLAGE
~~~CIFY Wappinger
D STREET ADDRESS 797 Old Route 9, Unit B1 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES't:J NO
08 /01 /1977
MONTH DAY YEAR
ZIP 12590
DYES '6 NO
,,%978
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE30 3B. DATE OF BIRTH 04 ~5
MONTH DAY
3. A AGE31
3B. DATE OF BIRTH
4. EMPLOYMENT
A USUAL OCCUPATION Lab Technician
B. TYPE OF INDUSTRY OR BUSINESS Medical
5. PLACE OF BIRTH Homabav , Republic Of Kenva
(CITY, STATE I COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTH City Of Newburgh
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Alphonso Patterson
'B. COUNTRY OF BIRT~amaica
17. MOTHER
A. MAIDEN NAME Pamela Marie Miles
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
6. FATHER
A NAME William Oyieyo Sure
B. COUNTRY OF BIRTH Kenva
7. MOTHER
A. MAIDEN NAME MarQaret Adovo AchienQ
B. COUNTRY OF BIRTH Kenya
8. NUMBER OF THIS MARRIAGE 2
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DATE
08/13/2008
YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN;;j;}" TC If i.~
c. LOCATION OF CEREMONY
(CHEJ< ONE AND SPECIFY)
~ITY OF }iJ TOWN OF 0 VILLAGE OF
SPECIFY ro~~/€,.,
I
A l.--L
NAME (PRINT)
SIGNATURE~