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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
5\t~n Roberkfio/~rR
I
STATE FlL.E NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY Outr.hess
CITYn-OWN Wappinger
~~~~~: 1 ?f\R
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FUUL NAME Jennifer L vnn Andrews
FIRST MIDDLE
CURRENT SURNAME
11. A.
CURRENT SURNAME
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N
B. BIRTH NAME, IF DIFFERENT PBtrick
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER ~~"-R7 - 7!=i70
2. RESIDENCE A. N'ViTX ork B q~~<::!'::
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D STREET ADDRESS :'.1 Degarm 0 Hills Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
07 /"9 / 1 g71
MOmtr DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Rivera
(OPTIONAL - SEE REVERSE) 014-12 0836
D. SOCIAL SECURITY NUMBER -
12 RESIDENCE A. New York B Dutchess
(STATE).J (COUNTY)
C. CHECK ONE 0 CITY LJ TOWN 0 VILLAGE
AND W .
SPECIFY apptnQer
D STREET ADDRESS 31 Degarmo Hills Road
ZIP 1l~!:IU
.,
o YES 0 NO
'W19
YEAR
3. A AGE 29
4. EMPLOYMENT
3B. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 26 3B. DATE OF BIRTH 11 ~8
MONTH DAY
14. EMPLOYMENT
A USUAL OCCUPATION Homemaker
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Mount Kisco, New York
(CITY. STATE I COUNTRY IF NOT USA)
A USUAL OCCUPATION Retail Management
B. TYPE OF INDUSTRY OR BUSINESS Circuit City
5. PLACE OF BIRTH Seattle WR~hinJ;J!on
(CITY, STATE' COUNTRY IF N USA)
6. FATHER
16. FATHER
A. NAME James Andrews
B. COUNTRY OF BIRTH USA
17. MOTHER
A MAIDEN NAME Dorothy Shane
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL AN~LMENT
DE1fiH
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A. NAME Angelo Rivera
8. COUNTRY OF BIRTH I' S A
7. MOTHER
A. MAIDEN NAME M8ry .ll'IImllewic7
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
o
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
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
o
o
o 0 1ST
o 0 2ND
o 0 3RD
o 4TH
i:l beliel that the inlonnation I provided is
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USEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State 01 the brii:le and groom named above by any person authorized
Relations Law 911 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o II checked, this license is to be used only for the purpose 01 a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE
by New York Domestic
,-'-.
{ SEAL }
'-v-'
on
YEAR
TIME
MONTH
YEAR
MONTH
NAME (PRINT)
05/11/200
2006
01
DATE
10 2006
AM
01 :1 O>M
05
12
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o ""'0' 0 0<... 0' ~= "'i<-. /1_
SPECIFY~;vb~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1'/fJ CIVIL
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-98 (07/2005)