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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Draper Remond Godette
FIRST MIDDLE
I"
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
COuN~utchess
CITYiTOWNWappinger
~~~:~ClI368
~5~~J~F65
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAMEHeleen P. Marino
FIRST MIDDLE
CURRENT SURNAME
11. A.
CURRENT SURNAME
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B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Godette
(OPTIONAL - SEE REVERSElI17 58-4346
D. SOCIAL SECURITY NUMBER I -
12 RESIDENCEI'-Jew York aDutchess
(STATE) ...L (COUNTY)
C. CHECK ONE 0 CITY LJ TOWN 0 VILLAGE
AND W .
SPECIF-,.-.!.applnger
D. STREET ADDRES~8 Widmer Road
ZIP12590
o YE~D NO
1913
DAY YEAR
B. BIRTH NAME, IF DIFFERENT
3. A. AG~8
12
MONTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGl31 13.B. DATE OF BIRTH 12 ~
MONTH
3B. DATE OF BIRTH
DAY
14. EMPLOYMENT
A. USUAL OCCUPATIO~ecretary
B. TYPE OF INDUSTRY OR BUSINESsGravrnoor
15. PLACE OF BIRTtMOunt Vernon. New York
(CITY, STATE/COUNTRY IF NOT USA)
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4. EMPLOYMENT
A. USUAL OCCUPATION Housekeeper
B. TYPE OF INDUSTRY OR BUSINESSGraymoor
5. PLACE OF BIRT~ite Plains, New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Clarence Bell Frazier
B. COUNTRY OF BIRTHU S A
7. MOTHER
A MAIDEN NAME Claudia Marie Godette
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
16. FATHER
A. NAM~oseph Marino
B. COUNTRY OF BIRrIJ S A
17. MOTHER
A. MAIDEN NAM$usan Wagner
B. COUNTRY OF BIRrIJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDE.EJ? MONTH / DAY / YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 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
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1ST 0 0 1ST 0 0
2ND 0 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 and that I declare that no legal Impediment eXists
as to my right to enter Into the marriage state. t{d -----vw
21 SIGNATUREOFGROOM~' 22.SIGNATUREnFBRIDE~L..L-Y1II( ~
~ USE CURRENT NAME
23 ~~~..fT~~~Do~Nto~Ot~ ~'?vBg~~~~E DATE 08110/2005
This license authorizes the marriage in New York State the bride and groom named above by any person authorized by New York Domestic
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 CJTY CLE!;lI5 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) .10 l,;:. Masterson
{ ~
SEAL SIGNATURE ~ DAT~8/10/2005
"-.t-' ~ltjfJJtam sh Rd, Wappinger Falls, NY 12590
STREET CITYITOWN STATE
~~~R~~~Ri~~~ IO~O~~N~ZEErf. 26 SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO.. DAY YEAR 0 0 RELIGIOUS 1 Il!( CIVIL
DATE AND AT THE TIME AND ., ,'A ~
PLACE INDICATED. ....... ~; PM :is. oS 9 0 OTHER, SPECIFY
I ../ ') ...-' -_ C J
29.0FFICIANT Vlrvc:c..17 ~-, f-r.>"../r'-:;('.f= IOi~lI'/$fJ'i(IV".N'l' - #"?q,
NAME (PRINT) . IV - ." t::::..'IllVv~- TITLE' "-,~,;,.,....... Jc.i: "', i
SIGNATURE ~ ;f-rj(;4?r1.fi41 ,H.J;~ DATE 0Ef'r. 2..5. Qt)c')S'
MAI~ING J>9.1JRESS..... - _' //) r.o tI (/
/1 \i:.S.~~t>ie r'--. ft.. 'lJff/rlB-E.{:.,s n't/J..s .Ii ../. /..2.590
STREET CITyrrOWN STATE
30. WITNESS TO CE
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28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. couN-rv1J..Jire(1JES.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF .. TOWN OF 0 VILLAGE OF
SPECIFY !!/,1PP/tVGJ-E12.
NAME (PRINT)
SIGNATURE ~
DOH-9B (11/9B)
31.
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NAME (PRINT)
SIGNATURE ~