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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael Joseph White
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c; 1368
~~~I~J~R 42
1 . A. FULL NAME
FIRST
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B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 073-72-3089
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY C!" TOWN 0 VILLAGE
~~CIFY Wappinger
D. STREET ADDRESS 25 E Alpine Drive
12590
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES cf NO
01 / 24 / 197
MONTH DAY YEAR
3. A. AGE 28
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Field Service Technician
B. TYPE OF INDUSTRY OR BUSINESS Cablevision
5. PLACE OF BIRTH Smithtown, New York
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
to-
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A. NAME George White
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Dianne Wissenbach
B. COUNTRY OF BIRTH USA
1
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY/COUNTY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Felecia Rushforth
MIDDLE CURRENT SURNAME
-.J
1 1. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Wh ite
(OPTIONAL' SEE REVERSE) 059-70-0902
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY cI TOWN 0 VILLAGE
AND W .
SPECIFY apQm~er
o STREET ADDRESS 25 E Alpine Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d NO
08 /05 /1981
DAY YEAR
13. A. AGE 25
3B. DATE OF BIRTH
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Newburgh Sch. Dist.
15. PLACE OF BIRTH West Islip, New York
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Arthur Paul Rushforth
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Jeanette Santo
B. COUNTRY OF BIRTH U S A
1
1 B. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHleH ENDED BY
DIVOCE CIVIL ANNOLMENT
DEAOH
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
. W'"_'_ '"
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
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH I 0 0 4TH
I duly swear/affirm, depose and say, thal'l~e best of my knowledg and belief that the information I provided is t
as to my right to enter into the mar e ~tate.
21. SIGNATURE OF GROOM. URE OF BRIDE.
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USE CUR NT ME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME . .
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York 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 St . THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used on y for the purpose of a secorid Qr subsequent ceremony.
~ 24. TOWN OR CITY pL~RK C M t 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) JOnn . as erson
{SEAL SIGNA"RJRE ~ . DATE OS/24/200 YEAR MONTH
'-v-I MAIL~O~eb h Rd, Wappinger Falls, NY 12590 2007 07 23 2007
STREET CITYITOWN STATE ZIP
~~~~~RT~~~ 'o~O~~~N:,z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME AY YEAR 0 il' RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
S~E""'" P e-,.. ~so IV
P ..j-J.., s t/)'\
It
A-Vf:. E R. S T"
CITYfTOWN
:r S IIp
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY S II PFOl../L
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
TITLE QOl'hln., ell~Lic: "h~
DATE 'Jt.~~ '2- J.OtJ 7
~A~E
SIGNATURE~ ~~
MAILING ADDRESS
~O ~~i rSl./N
STREET
30. WITNESS TO CER
NAME (PRINT)
SIGNATURE~
SPECIFY t:'~ :rS4r ~ All
NAME (PRINT)
SIGNATURE~
31. WITNESS TO C