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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~<;[1368 '
~5~';~~R 122
~ I"" II:; ur l'tl:; VV ,unn.
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael Brandon Keenum
MIDDLE CURRENT SURNAME
FIRST
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sha-quaya M Roscoe
MIDDLE CURRENT SURNAME
~
1 , A, FUll NAME
11, A, FUll NAME
FIRST
0-
N
B, BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)052_78_3593
D, SOCIAL SECURITY NUMBER
2, RESIDENCE A. New York B, Dutchess
(ST A1f) (COUNTY)
C, CHECK ONE '[] CITY 0 TOWN 0 VILLAGE
~~~CIFY Pou~hkeepsie
D, STREET ADDRESS 69 Verazzano Blvd ZIP 12601
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3, A. AGE 22 38. DATE OF BIRTH 07 / 12 / 1984
MONTH DAY YEAR
B, BIRTH NAME (MAIDEN NAMEl. IF DIFFERENT
C, SURNAME AFTER MARRIAGE Keenum
(OPTIONAL - SEE REVERSEl082_78_2126
D, SOCIAL SECURITY NUMBER
12 RESIDENCEA,New York BDutchess
(STATE) J. (COUNTY)
C, CHECK ONE 0 CITY LJ TOWN 0 VILLAGE
AND P hk .
SPECIFY ou~ eepsle
D, STREET ADDRESS 0 Haviland Rd; Apt C7 ZIP 12601
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES '6 NO
/04 )990
DAY YEAR
13, A, AGE 16
14, EMPLOYMENT
A, USUAL OCCUPATION Student
B, TYPE OF INDUSTRY OR BUSINESS F.D.R. High School
15, PLACE OF BIRTH Valhalla, New York
3B. DATE OF BIRTH
08
MONTH
4, EMPLOYMENT
A. USUAL OCCUPATION Framer
8. TYPE OF INDUSTRY OR BUSINESS Construction
5, PLACE OF BIRTH Cold Spring, New Yorl<
(CITY, STATE / COUNTRY IF NOT USA)
6, FATHER
A. NAME Michael Lewis Keenum
8. COUNTRY OF BIRTH USA
7. MOTHER
A, MAIDEN NAME Andrea Susan Kubeck
B. COUNTRY OF BIRTH USA
8, NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
(CITY, STATE / COUNTRY IF NOT USA)
16, FATHER
A, NAME Unknown
'B. COUNTRY OF BIRTHU S A
17, MOTHER
A. MAIDEN NAME Ramona L. Roscoe
8. COUNTRY OF BIRTHU S A
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D100RCE CIVIL A1)'ULMENT
DEATH
o
D10'TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 DIVORCE
B, HOW DID LAST MARRIAGE END?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
C, DATE LAST MARRIAGE ENDED?
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) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST 0 0 1ST
2ND 0 0 2ND
3AD 0 0 3AD
4TH 0 0 ~H
I duly swear/affirm, depose and say, that to e best of my knowledge and belief that the Information I provided is true a d t
as to my right to enter into the m'Wlage tat ,
21. SIGNATURE OF GROOM~ I 22, SIGNATURE OF BRIDE~ '
o
o
o
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New he bride and groom named above by any person
Relations Law ~11to perform marriage ceremonie . in 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 4LERK;...,. M t 25 A SOLEMNIZATION PERIOD BEGINS
JOnn lJ. as erson . ,
NAME (PRINT)
by New York Domestic
~
{ SEAL }
"-v-'
08/10/2006
DATE
appinger Falls, NY 12590
YEAR
10
09 2006
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED,
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
ZIP
1~L
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B, COUNTY ~Vi2 JIrIj
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~;~LAGE OF
w.)~"j,<'4
HJ6
SPECIFY
31,
NAME (PRINT)
SIGNATURE~
DOH.98 (03/2006)
/~
NAME (PRINT)
SIGNATURE~
,>>-
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
Certificate of Consent
::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::I::::::::::::jeRllfletlllJ.s.OOIIII::::::::I::j::::::::::::::::::::::::::::::::~::::::::::::::::::::::BIII:::lllll\l::IIRI:::::::::j::::::::::::j:::::::I:::::II:::::!)!j!:::::::::::jj!:I):):::j:j::::::::::))):
County tv District }i 3 (0 ?
n:-H e ~j Number
City~ iN AfP, N(; &K Register \ ~ \
Number
::IIIIINlt:511:::IIIIM:::::::::::::::::::::::::!:::!::::::::::::::I::)::::::::::::::::::::::::::::::::I:::::::':::':::::::::':::j::::::::::::::::::!:::::!:::::::::::::::::::::!:::::I::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::!::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::I::::::::::':::::::::':::::::':':::'::::::::j::::j::I:'::::::::::::::j::::::::::
This is to certify
, who have hereto subscribed
name, do hereby consent that
(I, we)
(my, our)
(name of minor)
who is and who is under the age of
(my or our son or ward)
years, shall be united in
marriage to
by any person authorized by law to solemnize marriages in New York State.
Witness my hand this
day of
20
~
~
~
(Signatures of Parents or Guardians)
(Signature of Issuing Clerk or a Notary Public)
::IIIS.lNltIIIIIRII.:::::::::::::~:::::::::::::::::::::::::::::::::j::j::j:j::::j:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::j:::::::::::::::::::::):I::::::::':::::::::::~!):::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::I::::::::::::::::'::::::::::::j:j:!::j:::::::::::jjj::)::j:):::::::::::::::::::::j:::I::::::::::::::::I
This is to certify &. , who have hereto subscribed /};vl j name, do hereby consent that
J.R __ (I, w,e) ~ (my, our)
P>. f~~ ~1 <y-fj.~(nale of min00
who is ~/ and who is under the age of
~or- ouf daugh~r or ward)
marriage to ~jI~ ~-(~
I r years, shall be united in
~/Yl .{.I <f ""'1.
by any person authorized by law to solemnize marriages in New York State.
Witness my hand this {1~
day of
.1/0 '
I
20
Ob
~
~ 1bJ./VVVt~ d' ~~/f
(Signatures oj Parents or Guardians)
~
gnature of Issuing Clerk or a otary Public)
~
(OVER)
DOH-2279 (4/2003) pg. 1 of 2