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COUNTY Dutchess
CITYiTOWN '^'appinger
~~~~~; 1368
~~~~~~R 73
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
RobeltREale Roar~UOORNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
MiirUd~~nn McL~~NT SURNAME
~
1. 'A. FULL NAME
11. A. FUll NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER 134-28-0'372
2. RESIDENCE A. NV B. n, ,tt"'hess
lSTATE) "fcoolWYl
C. CHECK ONE 0 clTY.Ill TOWN 0 VILLAGE
AND
SPECIFY Pleiiiiilnt \/iillley
D STREET ADDRESS 63 ElrTl1 ::mE' ZIP 1?!1R~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES olJ NO
3. A. AGE 60 3B DATE OF BIRTH MOW; / J.~ / y1i38
4. EMPLOYMENT
A. USUAL OCCUPATION Owner
B. TYPE OF INDUSTRY OR BUSINESS Deli Bllsine~s
5. PLACE OF BIRTH ~~, ~~mE~t~/?'-~J~No~XA)
6, FATHER
A NAME Dale Roarabaugh
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Bernice M BE'l:lch
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE ?
9, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. s~~~~~J".~~~~t~~b~~s~oarabaugh
D. SOCIAL SECURITY NUMBER ?c; 1-A.R-1 qc;n
12 RESIDENCE A, NY B D"tt"'h",ss
(STATE) (C~rnf1'\l'i'
C. CHECK ONE 0 CITY I;tI TOWN 0 VILLAGE
AND
SPECIFY PIE'~~::ll1t \/::lllpy
D. STREET ADDREssR~ Flm I ~ne ZIP 1 ?!169
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 72 38. DATE OF BIRTH ~TH ~gAY /of ~}R?
14. EMPLOYMENT
A. USUAL OCCUPATION Financial Analyst
8. TYPE OF INDUSTRY OR BUSINESS I RM
15, PLACE OF BIRTH (;rppnvillp r.nllntv Sr.
(CITY, STATE / COUNTRY IF NOT"USAI
16. FATHER
A, NAME Joe Da"is Mcleod
'B. COUNTRY OF BIRTH I J S A
17. MOTHER
A, MAIDEN NAME Cnr::l I PI" Fr::l~ipr
B. COUNTRY OF BIRTH II S A
18. NUMBER OF THIS MARRIAGE 2
19, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
n
DEATH
1
B, HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) ~DEATH
C. DATE LAST MARRIAGE ENDED? 03/ 04 / ?002
MONTH Dii'Y ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES &'No
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B. HOW DID LAST MARRIAGE END? (3) ~D1VORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? OA. / OA. / 19R3
MONTH DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? &'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 SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST OA.tn4/1~R~ nlltr.hp~~ r.n1mty, NY 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 and that I declare that no legal im ediment exists
as to my right to enter into the marnage state. ! ~ . _ -t9 /J. C
21. SIGNATURE OF GROOM~ t IGNATURE OF BRIDE~~
USE USE CURRENT NAME
23. sueSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New rk State of the bride and groom named above by any person authorized by New York Domestic
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
DATE 06/?~/?OOR
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25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON,
~
{ SEAL }
'-..,-I
YEAR
MONTH
DAY
YEAR
NAME (PRINT)
TIME
MONTH
AM
12:51PM
06
24
2008
08
22 2008
ZIP
1~
28. PLACE WHERE MARRIAGE OCCURRED
A, STATE NEW YORK B. COUNTY'd;)w\t.Hd
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF ~ILLAGE OF
SPECIFY ~~ ,.\f(,t0t\.4. ~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME A
PLACE INDICATED.
STREET CITYrrOWN STATE
30. WITNESS TO CEREMONY IJ
::::~: ~J(?tOL:;"~ >::-,bEtl
NAME (PRINT)
SIGNATURE~