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DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST R~ro~olph Rod~~iR~~~URNAME
~ I A II: tolLI: NUMIII:H
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY Dutchess
CITYfTOWN Wappinger
1368 '
46
L 0 SUPPLEMENTAL FILE
1.. A. FULL NAME
FROM THE BRIDE
PattiJo Smith
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT Veach
c. SURNAME AFTER MARRIAGE Rodriguez
(OPTIONAL - SEE REVERSE) 1 00-60-0127
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY O....TOWN 0 VILLAGE
~~~CIFY Wap~in-ger
D. STREET ADDRESS 11 F Alpine Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0"" NO
03 / 15 /1964
MONTH DAY YEAR
,1 1. A. FULL NAME
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 070-66-6021
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY D""TOWN 0 VILLAGE
~~CIFY Wappinger
D. STREET ADDRESS 11 F Alpine Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0"" NO
3. A. AGE 39 3B. DATE OF BiRTH 09 / 18 / 196
MONTH DAY YEAR
3B. DATE OF BIRTH
13. A. AGE 43
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Licensed Practical Nurse
B. TYPE OF INDUSTRY OR BUSINESS Nursing Home .
15. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE I COUNTRY IF NOT USA)
A. USUAL OCCUPATION Warehouse
B. TYPE OF INDUSTRY OR BUSINESS PRG Technologies
5. PLACE OF BIRTH Brooklyn, New Yark
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
6. FATHER
A. NAME Douglas Leroy Veach
'B. COUNTRY OF BIRTH U S A
A. NAME Santiago Rodriguez
B. COUNTRY OF BIRTH Puerto Rico
7. MOTHER
17. MOTHER
A. MAIDEN NAME Angelina Figueroa
B. COUNTRY OF BIRTH Puerto Rico
1
e. NUMBER OF THIS MARRIAGE
A. MAIDEN NAME Barbara Jean McQuade
B. COUNTRY OF BIRTH U S A
3
le. NUMBER OF THIS MARRIAGE
19. ~~~~~~?R~r~~~cvr8us MARRIAGES WHICH ENDED BY
DIV02CE CIVIL ANN'irENT
....
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 AN~LMENT 2BB~EATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 12/ 2 /
MONTH DAY YEAR MONTH .... DAY' - - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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) (CITYICOUNTY, STATEICOUNTRY,IF NOT USA) SELF SPOUSE (MOtlJJi/j)6.Y/)'~f!) .lAITYICOUNTY, ST~TflCOU~Y,IF NOT USA) SELF SPOUSE
o 0 1ST 0;jJ1 ( 1 ~lj9 ~mgston, New york 0....
o 0 2ND 1~/~U1~UU4 Ulster County, New york 0....
o 0 3RD 0
o 0 4TH 0
! oV1ll.,edge and belief that the information I provided Is true ent exists
. 9. ~~~~~~?R~R~~"lRJr8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEA 1)'
1ST
2ND
3RD
4TH,
I dulY swear/affirm, dep.OSB and sa
as to my right to enter into the m
21. SIGNATURE OF GROOM~ ~
22. SIGNATURE OF BRIDE~
USEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New Yo State of t e bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wlttiln 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 GLE,RK C M t 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) JOnn . as erson
{SEAL SIGNATURE ~ DATE 06/06/200 TIME MONTH YEAR
MAILI~Wftffi1 ush Rd, Wappinger Falls, NY 12590 06:2~ 06 07 200
'-.,-I STREET CITY/TOWN STATE ZIP
~~R~~Rir~J lo~O~~N:.zi~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME M. DAY Y AR oWl RELIGIOUS
~~~E ~~gIC~~~E TIME AND AM "1 2.. J c 1 9 0 OTHER, SPECIFY
YEAR
1 0 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED . /J
A. STATE NEW YORK B. COUNTY ])J!;;hL,
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF -f"rOWN OF 0 YILLAGE OF
SPECIFY W~
::::~JL~~~ : ~~7:~
MAILI~fci~~ ~ \ I J
12 \p ~<S.~~ ~~c... '-.Lt"'''~j'k''''''~ ~~ ."' ,~~x. I ~\.."(~)
STREET CITY~ ~ STATE ZIP
30. WITNESS TO CEREMONY. ( ,.-- S 31. WITNESS TO ER or
NAME (PRINT) /Y7 I c)-,l(ol, (Cv./.., sl NAME (PRINT) ~(...
t~, (1 ~.
SIGNATURE~ -
.'
IrSc;
SIGNATURE~
DOH-98 (03J2006)