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053 FULL NAME STATE OF NEW YORK DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and ~CERTIFICATE OF ~~: -'iANT 10 MARRIAGE FROM THE GROOM Joe Lewis William~i JR. MIDDLE UR NT SURNAME ~i~:~ f~.:r ~~}~' H . f)" ~ '.'i ~ :1: _.r": >:f, "'~'1!!!u1: i SUPPLEMENTAL FILE q ~ ~;;'1-" ~ ~ FROM THE BRIDE Juliet Pamela Roach FIRST MIDDLE CURRENT SURNAME STATe FILe NUMBeR (THIS SPACE FOR STATE USE ONL Y) I COUNTY Dutchess CI'NfTOWN WappinQer ~~~:~c: 1368 . REGISTER 53 \ ,UMBER -?\ cr.""" -- !z w '" ~ Q 9 u:: 5 u. ill c( z 0 ~ Ii; a w a:: w ~ a:: I ~ ~ !.1 LL ~ W 0 w a:: w i '" '" z w a:: 0 ~ z .. tii ~ w 0 ~ ~ w en z w (.) ::J + ~~~ ~i;:: a::"~ Ii;~~ ::>O~ ~!i~ ~~~ it 0'" 01-> ..w~ I!!~", o~z z-,_ FIRST 11, A. FULL NAME B. BIRTH NAME. IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL - SEE REVERSE) 115 68 0083 D. SOCIAL SECURITY NUMBER -- ~ RESIDENCEA. New York B. Dutchess (STATE) (COUNTY) C. CHECK ONE 0 CITY cYTOWN 0 VILLAGE ~~~CIFY Wappinger D. STREET ADDRESS 8 Brothers Road ZIP 12590 ~. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES o'NO . . AGE 24 38. DATE OF BiRTH 04/ 08 / 198 MONTH DAY YEAR . MPLOYMENT A. USUAL OCCUPATION Security B. TYPE OF INDUSTRY OR BUSINESS U. S. I. ~;JCE OF BIRTH Mount Vernon, New Yorl< (CITY. STATE I COUNTRY IF NOT USA) . HER A. NAME Joe Williams B. COUNTRY OF BIRTH USA 7. MOTHER B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT C. SURNAME AFTER MARRIAGE Roach - Williams (OPTIONAL. SEE REVERSE) 580-21-9236 D. SOCIAL SECURITY NUMBER 12. RESIDENCE A. New York B. Dutchess (STATE) (COUNTY) C. CHECK ONE 0 CITY D""TOWN 0 VILLAGE AND W . SPECIFY appmQer D. STREET ADDRESS 8 Brothers Road ZIP 12590 E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES if NO 13. A. AGE 28 3B. DATE OF BIRTH 09 / 04 /1978 MONTH DAY YEAR 14. EMPLOYMENT A. USUAL OCCUPATION Police Officer B. TYPE OF INDUSTRY OR BUSINESS City Of Mount Vernon 15. PLACE OF BIRTH St. Croix U. S. V. !. (CITY. STATE I COUNTRY IF NOT USA) 16. FATHER A. NAME Eustace Roach . B. COUNTRY OF BIRTH Antigua 17. MOTHER Ernestine Perry B. COUNTRY OF BIRTH USA 8. NUMBER OF THIS MARRIAGE 1 A. MAIDEN NAME A. MAIDEN NAME Catherine Rebecca Jarvis B. COUNTRY OF BIRTH St. Croix U. S. V. I. 1 1B. NUMBER OF THIS MARRIAGE 9. ~~~~~d'IR~~~~US MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT o 0 19. PREVIOUS MARRIAGES A. NUMBER OF PREVfOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT o 0 DEATH o DEA'Q 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? DYES D NO 10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION DATE OF DECREE PLACE ISSUED AGAINST WHOM (MONTH, DAY, YEAR) (CITYICOUNTY. STATElCOUNTRY. 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) (CITYICOUNTY. STATElCOUNTRY. IF NOT USA) SELF SPOUSE (3) 0 ANNULMENT (2) 0 DEATH / / - YEAR 1ST 2ND 3RD 4TH I duly swear/affirm, dep.ose and s as to my right to enter into the m 21. SIGNATURE OF GROOM~ 0 1ST 0 0 0 2ND 0 0 0 3RD 0 0 0 0 d that I declare that no legal impediment exists UECUR 23. SUBSCRIBED AND SWOR IAFFIRMED BEFORE ME SIGNATURE OF TOWN OR CITY CLERK ~ DATE This Iicanse authorizes the marriage in New York State of.t authorized by New York Domestic Relations Law ~11 to perform marriage ceremonies within New York te. THIS LICENSE VALID IN NEW YORK STATE ONLY. o If checked, this license is to be used only for the u se of a second or subsequent ceremon . ~ 24. TOWN OR CITY C1LE K 25. A. SOLEMNIZATION PERIOD BEGINS } NAME (PRINT) JO C. Mas erson {SEAL SIGNATURE ~ ' DATE 06/19/20 TIME MONTH YEAR MONTH ~ MAILI~l}OO~dle appinger Falls, NY 12590 01:5~ 06 20 200 08 18 2007 STREET CITYITOWN STA P ~~iR~~RT:~J 'o~OL~~N~~E~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY SONS NAMED ABOVE ON THE TIME Y YEA 0 ~LIGIOUS DATE AND AT THE TIME AND PLACE INDICATED. 0 OTHER. SPECIFY YEAR B. PLACE WHERE MARRIAGE OCCURRED 10 CIVIL STATE NEW YORK B. COUNTY bu J.e. ~t ~ LOCATION OF CEREMONY ~J ~ J ; (CHECK ONE AND SPECIFY) V (Il.J o CITY OF ~WN OF VILLAGE OF " . I 611 c:::. J N v- SPECIFY W~ fW"'- N~ c.~___ 6_ ts: f- Oeacon Isiah White Chairman of Deacon Board Mount Zion Christian Baptist Church 411 South EighthAvenue Mount Vernon, New York 10550 Church Phone: (914) 667-2079 Church Fax: (914) 667-2944 Rev. Peter Wilson, Sr., Pastor (914) 667-2218 Sister Gwendolyn James Church Clerk Sister Florence White Chairlady ofTruslee Board Sister Ericka Jackson Assistant Church Clerk A.- 27~ 2001 em. Ma~$(rI) Town Clerk's Office 2O~Road Wappingers Falls. NY 12590 Dear Mr. Mastersoo: I ~1lIed the lD8l'J'iap eeremony of Joe LewiI Wj}~ k. lIDd Juliet Pamela RoadI. on August 18, 2007. The ceremony took place at 8 Brothers Road, Town of Wappinger. I filled in bloek ~I meoli~tl,. llle plate ofJllllltiap should have sUIted T...... Wappinger, but I specified Wappingers Falls. Thanks to you aM your (Jifiee- for 8RiItift& me- wiih. this matter. Repnk &c U~ ~L. Rev. Peter Wilsoua Sr. ' 111'\11 STATE OF NEW YORK ., DEPARTMENT OF HEALTH Corning Tower The Governor Nelson A. Rockefeller Empire State Plaza Albany, New York 12237 September 14, 2007 Groom: Bride: Joe Lewis Williams, Jr. Juliet Pamela Roach Dear Town/City Clerk: Enclosed is a copy of the marriage referred to by the above file in your office. Correction to the original has been made based on: D Affidavit ~ Officiant's Statement D Signature on original marriage affidavit D Statement verified by City/Town Clerk D Other: Supplemental Please file this amended record along with the supporting documentation. If you have any questions, please call us at (518) 486-3301. Q;:JLJ Arleen Meres New York State Dept. of Health Vital Records Section Marriage Registration Unit P.O. Box 2602 Albany, NY 12220-2602 Enclosure TOWN OF WAPPINGER TOWN CLERK CHRIS MASTERSON SUPERVISOR JOSEPH RUGGIERO TOWN CLERK'S OFFICE 20 MIDDLEBUSH ROAD WAPPINGERS FALLS, NY 12590 (845) 297-5771 FAX: (845) 298-1478 TOWN COUNCIL WILLIAM H. BEALE VINCENT BETTINA MAUREEN McCARTHY JOSEPH P. PAOLONI Peter Wilson, Sr. 22 Esplanade Mount Vernon, NY 10553 Dear Minister Peter Wilson, Sr., My office has received a photocopy ofthe Marriage License for the marriage of Joe Lewis Williams, Jr. and Juliet Pamela Roach, which you performed on August 18th, 2007. Please be advised that a photocopy is insufficient, and that the original needs to be filed with my office. At the time oflicensing, my office provided the couple with a memo that would assist you in the completion of block #28. The information that you entered into block #28 is incorrect. There is no Town ofWappingers Falls. The entry should have read "Town of Wappinger" or "Village ofWappingers Falls", depending on the location of the wedding. I am enclosing a DOH-1827: Affidavit for Correction of Marriage License. The affidavit "must be signed by both the husband and wife in the presence of a notary public". Documentation is also required to make corrections to the Marriage License. In this case, sufficient documentation is: . a letter from the officiant, on official letterhead, or . a certified copy of the officiant's record, or . a Church Certificate with seal Please mail the affidavit and documentation to my office at your earliest convenience. 1 C.Ma own Clerk Town of Wappinger cc: Joe LewisWilliams, Jr. Juliet Pamela Roach Ene. ister Florence White hairlady a/Trustee Board Mount Zion Christian Baptist Church 411 South Eighth Avenue Mount Vemon, New York 10550 Church Phone: (914) 667-2079 Church Fax: (914) 667-2944 Rev. Peter Wilson, Sr., Pastor (914) 667-2218 Sister Gwendolyn James Church Clerk leacon lsiah White 'hairman a/Deacon Board Sister Ericka Jackson Assistant Church Clerk A~ 21,2001 Cbril~.~ Town Clerk's Office 2fi.~R<<Kt Wappingers Falls. NY 12590 Dear Mr. ~ 1 ~.f~ the.mafJ';iaF ceremooy of Joe.Lewis. Williami. H. ftDt.i. Juliet hmda R~ on August 18,2007. The ceremony took place at 8 Brothers Road, Town of Wappinger. lliUed in iJkJek #21 mem~. ~ plae~ of~ should havl; Muted TfIWII fIf Wappinger, but I specified Wappingers Falls. 1'hanki to you atWyour ofiee.fw uNtina me. with this matter. ReganW. ~ J~ 5L, !lev, Peter Wi1soo. Sr.