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COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c; 1 368
~~~I~~~R 90
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Leslie Michael Paterson
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Laura Jean Williams
MIDDLE CURRENT SURNAME
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Paterson
(OPTIONAL - SEE REVERSE) 074-60-7128
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY r( TOWN D VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 7 C Whitegate Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES d' NO
13 A. AGE 38 38. DATE OF BIRTH 04 /03 /1'968
MONTH DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1 06 50-9542
D. SOCIAL SECURITY NUMBER -
2 RESIDENCE A New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~~CIFY Wappinqer
D STREET ADDRESS 7 C Whitegate Drive
12590
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES 1:'1 NO
09 / 07 / 1971
MONTH DAY YEAR
3. A. AGE 34
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Supervisor
B. TYPE OF INDUSTRY OR BUSINESS The Gap
5. PLACE OF BIRTH White Plains, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Donald Kustrup Paterson
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Luz Saiz
8. COUNTRY OF BIRTH Cuba
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Secretary
B. TYPE OF INDUSTRY OR BUSINESS Physician/ Westchester
15. PLACE OF BIRTH Yonkers, New York
(CITY, ST ATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Albert James Oliver
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Loretta Mary Chamberlain
8. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL AN'(YLMENT
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B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
c. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
1ST
2ND
3RD
D
D
D
1ST
2ND
3RD
D D
D D
D D
D D
I i ediment exists
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21. SIGNATURE OF GROOM~
USE CURRE NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR C'IJ8fi'hK C;:'.Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) ,"
DATE
by New York Domestic
~
{ SEAL }
~
ZIP
2006
09
09 2006
MONTH
YEAR
YEAR
07/11/200
DATE
ails, NY 12590
SIGNATURE ~
MAI~ WRffiJl'eb
STATE
27. TYPE OF CEREMONY
o ~ELIGIOUS
9 D OTHER, SPECIFY
CITY /TOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
~
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. couN;;puIvlt~S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF ~OWN OF D VILLAGE OF
SPECIFY {. S~ ~..(/
1 D CIVIL
Db
TITLE C. +I.o1,t. 7 rt~ d..
DATE~Oh
}.J
J2.$2
ATE
31.
NAME (PRINT)
SIGNATURE~
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)