093
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rohert .Jerel Harris
MIDDLE CURRENT SURNAME
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY Dutchess
CITYITOWN Wappinger
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~~~I;~~R 93
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jacqueline Emma Smith
MIDDLE CURRENT SURNAME
11. A. FULLNAME
1 . A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE H a rri s
(OPTIONAL. SEE REVERSE) 122 68-0297
D. SOCIAL SECURITY NUMBER -
12. RESIDENCE A. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r:Y TOWN 0 VILLAGE
~~~CIFY Wappinqer
D. STREET ADDRESS 14 pye Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r:f NO
02 /02 /1979
MONTH DAY YEAR
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 452-93-1817
2. RESIDENCEA. Texas B Montgomery
(STATE] (COUNTY)
C. CHECK ONE [!f CITY 0 TOWN 0 VILLAGE
~~~CIFY Con roe
D. STREET ADDRESS 719 College Street ZIP 77301
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? dYES 0 NO
3. A. AGE 24 3B. DATE OF BIRTH 09 / 1 0 / 1981
MONTH DAY YEAR
+
13. A. AGE 27
38. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Willis Indep. Schl. Dist.
15. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE / COUNTRY IF NOT USA)
4. EMPLOYMENT
A. USUAL OCCUPATION Operator / Technician
B. TYPE OF INDUSTRY OR BUSINESS Unemployed
5. PLACE OF BIRTH Harris County, Texas
(CITY, STATE / COUNTRY IF NOT USAI
16. FATHER
6. FATHER
A. NAME Gerald Marvin Smith
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Marina Scarlet Game
B. COUNTRY OF BIRTH India
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
A. NAME Kenneth Rav Harris
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Donna Jo Richardson
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
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(3) 0 ANNULMENT (2) 0 DEATH
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- YEAR
(3) 0 DIVORCE
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
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
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
pediment exists
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o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
f my knowledge and belief that the information I provided is lrue and that I declare that no legai .
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21. SIGNATURE OF GROOM"
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25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON;
YEAR
STATE
27. TYPE OF CEREMONY
o rJ.. RELIGIOUS
9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYDutc\\e. SS"'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
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NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-98 (03/2006)
SIGNATURE~