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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Donevan Lee South
FIRST MIDDLE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITYiTOWN Wappinger
~~J~~cd 1368
~5~~J~R 152
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
CURRENT SURNAME
11. A. FULL NAME "n9~~A ~hP-pA~IDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Daniel
c. SURNAME AFTER MARRIAGE SOl dh
(OPTIONAL - SEE REVER.. SE) n""Rn..1""rR
D. SOCIAL SECURITY NUMBER _!1~___ ~::'-
12. RESIDENCE A. NP.MfAX)nrlf B. ~Mss
C. CHECK ONE 0 CITY I!I' TOWN 0 VILLAGE
AND W .
SPECIFY ~plnger
D. STREET ADDRESS 100 Scarborough Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13 A AGE 43 13.B. DATE OF BIRTH n,;; .(~ . .(,;;.,
. . '1.1CNTH 4.1' DAY ~AR
CURRENT SURNAME
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 113-66-658"
D. SOCIAL SECURITY NUMBER - ------,;!
2. RESIDENCEA. New York B. Old~hess
(sTATE) (~UN~)
C. CHECK ONE 0 CITY 1!1 TOWN 0 VILLAGE
AND W .
SPECIFY aDDlnaer
D. STREET ADDRESS 100 ScarborouQh Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
3. A. AGE 54 3B. DATE OF BIRTH n~ /nR / jQI\1
MONTH DAY YEAll'
4. EMPLOYMENT
A. USUAL OCCUPATION Senior Nuclear Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Enterav
5. PLACE OF BIRTH Jamaica. West Indies
(CITY, STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Nurse's Aide
B. TYPE OF INDUSTRY OR BUSINESS Anytime Home~are Agn~y
15. PLACE OF BIRTH Trinidad, West Indies
(CITY, STATE/l;OUNTRY IF NOT USA)
16. FATHER
A. NAME
B. COUNTRY OF BIRTt-Nla
17. MOTHER
A. MAIDEN NAME ~Ary MAgrlAIp-np- n~niel
B. COUNTRY OF BIRTH Trinidad I West Indie!;
lB. NUMBER OF THIS MARRIAGE 2
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6. FATHER
A. NAME PhilliD South
B. COUNTRY OF BIRTH Jamaica. West Indies
7. MOTHER
A. MAIDEN NAME Gloria Robertson
B. COUNTRY OF BIRTH Jamaica. West Indies
8. NUMBER OF THIS MARRIAGE 3
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT
2 0 0 1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 03 / 24 / 1999 c. DATE LAST MARRIAGE ENDED? 08 / 08 /1997
MONTj;!, DAY YEAR MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? l.J YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? i!!YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 01/1111992 White Plains, New York r:1 0 1ST 08108/1991 Wake l-Q Nn l-ArnlinA ~ 0
2ND 03124/1999 Poughkeepsie, New York ~ 0 2ND . 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true a gal impediment exists
as to my right to enter intD the marri state.
DEATH
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21. SIGNATURE OF GROOM ~
DATE 12/14170n5
by New York Domestic
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23. SUBSCRIBED AND SWORN TO 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.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) ~ter.sOR...-.-..
SEAL SIGNATURE ~~M.~'. :'~",'J"_ :-~~ DATE 12/14/2005 TIME MONTH YEAR
'-.,t-I M~'Mfd'arihush 'Rd',WaDDinoer Falls. NY 12590 ..56 ~~ 12 15 2005
STREET CI~rrowN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26 SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER- .
SONS NAMED ABOVE ON THE TIME MO. AY YEAR 00 RELIGIOUS
DATE AND AT THE TIME AND to 1IiIi!r
PLACE INDICATED. ..:.- PM 9 0 OTHER, SPECIFY
02
12 2006
MONTH
YEAR
l~CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
'.,
A. STATE NEW YORK B. COUNTYJ'){,rrr.:tIC~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF J!f TOWN OF 0 VILLAGE OF
SPECIFY u)A1'Pi~
If RJ '1- 'I1fP I.
EET CITYiTOWN
MW'm''''~ ~
NAME (PRINT)' 7' /IJ fv I {clOSt>
SIGNATURE ~ ~
DOH-98 (11/98)
31.
NAME (PRINT)
SIGNATURE ~