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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Derrick Holmes
FIRST MIDDLE
23. SUBSCRIBED AND SWORN TO BEFORE ME DATE 11..-..-.-r
SIGNATURE OF TOWN OR CITY CLERK. --~
This license authorizes the marriage in New York St person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within ew 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT)~' Masterson
{SEAL SIGNATURE. C1/lP::. DATE11/2212OO5
'-v-I ~W8il Rd. WaPlinger Falls. NY 12590
STREET CITYfTOWN STATE ZIP
~~~R~~Ri~~~ IO~O~~~N~:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY Y AR ~CIVIL
DATE AND AT THE TIME AND tyO
PLACE INDICATED. .--
COUNTY Dutchess
CITYfTOWN WaPPInger
~~J~~CRT 1368
~~I~J~R 141
1. A. FULL NAME
CURRENT SURNAME
a.
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEllV'llA D"\ 720il
D. SOCIAL SECURITY NUMBER ~-
2. RESIDENCE A. New Yark B. nutr.hA!ul
(STATE) (COUNTY)
C. CHECK ONE . D CITY ~ TOWN D VILLAGE
AND ~____i
SPECIFY ,,~e
o STREET ADDRESS 1 Mandlley DrIve ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIULAGE? D YES ~ NO
3. A. AGE41 3B.DATEOFBIRTH 11 /?? /1QR.4
MONTH DAY YEAR
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4. EMPLOYMENT
A. USUAL OCCUPATION correction omcer
B. TYPE OF INDUSTRY OR BUSINESS Dect. Of Corrections
5. PLACE OF BIRTH Manhattan. New York
(CITY, STATE/COUNTRY IF NOT USA)
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6. FATHER
A. NAME Rufus Holmes
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Besse MotMrIe
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 3
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
2 0
B. HOW DID LAST MARRIAGE END? (3)~ DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 03 / 28 /2001
MO~ DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? TI YES D NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED . AGAINST WHOM
(MONTH, DAY. YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1 ST O8J03I1993 Bronx. New York
2ND 0Yl8I2001 Bronx. New York
DEATH
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21. SIGNATURE OF GROOM.
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29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE.
DOH-98 (11/98)
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Di~ E. Cul~
, 1. A. FULL NAME
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~~:R"~~~t~~e~~s~mes
D. SOCIAL SECURITY NUMBER Q98..4&.0082
12. RESIDENCEA'~A~prk B. ~
C. CHECK ONE D CITY tl TOWN D VILLAGE
~~~CIFY PJ. --ant VAlIP.)f
D. STREET ADDRESs57 DftwnIF'SJ ~ftAd ZIP 12569
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIULAGE? DYES otJ NO
13. A. AGE48 13.B. DATE OF BIRTH 'In ..t... ....{-
'IJIONTH ~DAY ItfDfEAR
14. EMPLOYMENT
A. USUAL OCCUPATIONRMltor
B. TYPE OF INDUSTRY OR BUSINESS ERA Teem IV Homes
15. PLACE OF BIRTH~~~~n~NXRfk
16. FATHER
A. NAMEG~ AIfr~ O"~r
B. COUNTRY OF BIRTf\J S A
17. MOTHER
A. MAIDEN NAME Phyllis Milton Nlughton
B. COUNTRY OF BIRT" J S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1
DEATH
o
B. HOW 010 LAST MARRIAGE END? (3)otl DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? MONR3 / ~l /2qQ'
D. ARE ANY FORMER SPOUSE(S) ALIVE? otl YES D NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST~Af.)M1 Bronx. New York
2ND
3RD
4TH
)et that the information I provided is true a
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@ D
D D
D D
D D
pediment exists
2. SIGNATURE OF BRIDE.
TIME
MONTH
YEAR
MONTH
YEAR
.17
AM 1
PM
.23
2005
1
21 2008
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN;;n tL:.'fI !J..n.,
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D VILLAGE OF