146
m
o
1,0
N
..-
.l&
L..
~
I
:iI
o
g
J
j
1
!
j
W
II
(/)
(/)
W
a:
o
o
'"
>-
U-
ti
W
ll.
(/)
~:i:z
~~g w
:l!~~ ~
I-WZ -
~d~ 0
~~g i!
z-
i3~~ i=
tEO(/) a:
01->- W
w~~ 0
b~~
Z::J~
1. A.
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FULL NAME ~ Rufus L~nce
r
STATE FilE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
"I
COUNTYDulche,s
CITYITOWN Wappinger
~~~~~c~ 1368
~5~I~J~R146
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
--1
Q.
N
11. A. FULL NAME JCAy'l-p.r.eliA niaz;
CURRENT SURNAME FIRST MIDDLE
B. BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT TAylor
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE I AWfenr.e
(OPTIONAL _ SEE REVERSE) (OPTIONAL - SEE REVERSE!..
D SDCIAL SECURITY NUMBER 118;52.-7593 D. SDCIAL SECURITY NUMBER u66-54-5159
2 RESIDENCE A. N "'TATEI B. ~S, 12. RESIDENCE ANe!TAX; ork B D~~~~~s
C. CHECK ONE 0 CITY oll TOWN 0 VilLAGE C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY East Fisbkill ~~~cIFYFishkill
D. STREET ADDRESS ~ntdh Green Haven Road ZIP 12582 D. STREET ADDRESs3E Van Cortland Circle
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"6 NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE42 3B. DATE OF BIRTH "7 /g7Ay /1Q~3 13. A. AGE43 13.B. DATE OF BIRTH 0":\ t1
MtlNTH ffii ~ troNTH DAY
4. EMPLOYMENT 14. EMPLOYMENT
A. USUAL OCCUPATION Caretaker A. USUAL OCCUPATION Decorator
B'. TYPE OF INDUSTRY OR BUSINESS Nyr. HOlJ!~ing Authority B. TYPE OF INDUSTRY OR BUSINEssA & P
5. PLACE OF BIRTHMAn,hSTsdtArtTNyP.WNOTYUSAn)rk 15. PLACE OF BIRTH6altimore.1 Marvland
"(e1'l"r ~.. ~lFiiiC (CITY. STATE/COUNTRY WOT USA)
6. FATHER 16. FATHER
A. NAME RufUs Lawrence A. NAME Paul I Awrence Taylor
B. COUNTRY OF BIRTH l J ~ A B. COUNTRY OF BIRT.u S A
7. MOTHER 17. MOTHER
A. MAIDEN NAME Veronica Ann Wodhy A. MAIDEN NAME fu'AridA MAP. ~AV8ge
B. COUNTRY OF BIRTH II S A B. COUNTRY OF BIRTJ) 5 A
8. NUMBER OF THIS MARRIAGE , 18. NUMBER OF THIS MARRIAGE 2
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
1 0 0 1 0
B. HOW DID LAST MARRIAGE END? (3) tI DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE iND? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? "8 /'7 /1999 c. DATE LAST MARRIAGE ENDED? 12 /07 /2000
MONTI-' DAY YEAR MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ 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 ~POUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST 08127f1Q9Q pnughlrp.p.pRie, Np.w Ynrk 0 r!f 1ST 1210712000 poughkeepsie, New York . 11
2ND 0 0 2ND 0
3RD 0 0 3RD 0
4TH 0 0 4TH
I, being duly sworn, depose a~that 0 the il8St. 0 knowledge and belief that the information I provided is true and tbat I deel
as to my right to enter into the . st ~ ~ ~
21. SIGNATURE OF GROOM ~ G ~ 22. SIGNATURE OF BRIDE ~ ,/;. .
USE CURRENT NA
CURRENT SURNAME
ZIP 12508
DYES "fJ NO
1~'
YEAR
W
!;(
I-
m
....
:>
<(
c
w-
ou..
:5u..
~<(
Z
;:
o
t:
1:
u
DEATH
o
a:
W
lD
:;
=>
Z
Cl
Z
<:
I-
W
W
a:
I-
m
...
w
en
z
w
o
::::i
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Sta e 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) ~~~
SEAL SIGNATURE ~.. Cj1J~ DATE 11/2912005
MAILING ADDRESS .' ._' AM
'-v-' ,n Middlp.liu~trRd Wappinoer Falls, NY 12590 01".34 PM 11
STRE8 ' CITmQWN ~ STATE ZIP
~~~R~~~RT~~~ IO~O~~~N~:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS ~IL
DATE AND AT THE TIME AND ~ 1,,1\
PLACE INDICATED. 9 0 OTHER. SPECIFY
01
28 2006
by New York Domestic
YEAR
MONTH
YEAR
TIME
MONTH
30
2005
29. OFFICIANT
NAME (PRINT)
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF gtOWN OF 0 VILLAGE OF
SPECIFYWd-1f' \l~ e r
SIGNATURE ~
DOH-98 (11/98)
SIGNATURE ~