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COUNTY Dutchess
C1TYfTOWN WappinQer
~~~:~c; 1368 '
~5~1:~R 34
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFADAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert Ga~ Koch
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
Lo
1, A. FULL NAME
11. A. FUll NAME
SUPPLEMENTAL FILE
FROM THE BRIDE
Nadine Bautista
MIDDLE CURRENT SURNAME
FIRST
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE Koch
(OPTIONAL - SEE REVERSE) (OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 084-38-9206 D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NAW Ynrk B. Dutchess 12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY) (STATE) (COUNTY)
C. CHECK ONE 0 CITY [Y'TOWN 0 VILLAGE C. CHECK ONE 0 CITY D~TOWN 0 VilLAGE
AND AND P hk .
SPECIFY Poughkeepsie SPECIFY oug eepsle
D. STREET ADDRESS 75 ChanninQville Road ZIP 12590 D. STREET ADDRESS 75 Channingville Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES D"" NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES if NO
3. A. AGE 47 3B. DATE OF BIRTH 03/ 06 / 196 13. A. AGE 30 3B. DATE OF BIRTH 03 / 27 /1977
MONTH DAY YEAR MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Truck Driver
B. TYPE OF INDUSTRY OR BUSINESS Tech Air
5. PLACE OF BIRTH White Plains. New York
(CITY, ST..TEI COUNTRY IF NOT US")
14. EMPLOYMENT
A. USUAL OCCUPATION Unemploved
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Talisav, Cebu Philippines
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
16. FATHER
A. NAME Bertito Bautista
'B. COUNTRY OF BIRTH Philippines
17. MOTHER
A. NAME Fred Koch
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Patricia Grace Winterer
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 1
9. ~~~~~~R~~~h~~8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
A. MAIDEN NAME Mav Racaza
B. COUNTRY OF BIRTH Philippines
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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) (CrTYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH, 0 0 4TH
I duly swear/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is t
as to my right to enter into the mamage state.
21. SIGNATURE OF GROOM~
u
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of th
Relations Law ~11 to perform marriage ceremonies within New York S . THIS LICENSE VALID IN NEW YORK TE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony,
,-I'-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) John C. Ma terson TIME MONTH YEAR
SEAL SIGNATURE ~ DATE 05/07/200
"- .-.J MAILlfi.q"AQD}.lI.~1 AM
-v- LU Mlaa a in er Falls NY 12590 02:5~ 05 08 200
STREET CrTYlTOWN STATE ZIP
i~~R~~RT~: IO~O~~N:,z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. AY YEAR 0 ~ RELIGIOUS
DATE AND AT THE TIME AND 11 ~ 6 2 07
PLACE INDICATED. : vk - - 9 0 OTHER, SPECIFY
o 0
o 0
o 0
o 0
e that no legal impediment exists
05/07/2007
DATE
by New York Domestic
MONTH
YEAR
07
06 2007
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY Dutchess
~~~t~~c;:~ Daniel B. Ward
SIGNATURE~~~~
MAILING ADDRESS
St. John's Lutheran Church
STREET CITYfTOWN
30. WITNESS TO CEREMONY
NAME (PRINT) Stev Koch
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
Pastor
TITLE
Ck CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY Poughkeepsie
DATE
6-2-07
55 Wilbur Blvd. Pok, NY 12603
STATE
SIGNATURE~
DoH-98 (0312006)
ZIP
31. WITNESS TO CEREMONY
NAME(PRINT) ~ Barnes
SIGNATURE~ . 41~ ~~