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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Kwame Seen Heywood
FIRST MIDDLE
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
UH 0 0 UH 0 0
I, being duly swpm, 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. ~
21. SIGNATUREOFGROOM~ . SIGNATURE OF BRIDE ~ ~Of/..f~ .
USE CURRENT NAME
23. SUBSCRIBED ANO SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York S te of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies with New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is 0 be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR ~lE~ Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) . .
SEAL SIGNATURE ~ - DATI!!!.10512rKJ5
'-,-I .nger Falls, NY 12590
COUNTY .PtJtchess
. CITYfTOW~ Wlpplnger
DISTRICT 1368
NUMBER
REGISTER 50
NUMBER
1. A. FULL NAME
CURRENT SURNAME
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEl 02~ ~O
D. SOCIAL SECURITY NUMBER -~,
2. RESIDENCE A. New York B. Dutchess
(STATE) rJ! (COUNTY)
C. CHECK ON!,.. q CITY TI TOWN 0 VILLAGE
~~~CIFY WBppingel'
D. STREET ADDRESS 13 AeldItOne BoUlevard ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
03 /29 /1gn
MONTH DAY YEAR
3. A. AGE28
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION RegildpNurse
B. TYPE OF IND~ B= West. HosD.
5. PLACE OF BIRTH '
(CITY. STATElCOUNTRY IF NOT USA)
6. FATHER
A. NAME \Ninston P. Heywood
B. COUNTRY OF BIRTH Tnnldld
7. MOTHER
A. MAIDEN NAME Marvo Totah
B. COUNTRY OF BIRTH Berbedos
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVerCE CIVIL A'l)'UlMENT
DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(31 0 ANNULMENT
/ /
(2) 0 DEATH
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
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STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE.
11. A. FULL NAME Marcie Samuelle B8If
FIRST MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~
(OPTIONAL - SEE REVERSE)ru::~ ~ ~~
D. SOCIAL SECURITY NUMBER ~~
12. RESIDENCEA.Nll!!WVork: B.~
~m) ~)
C. CHECK ONE 0 CITY 'tl TOWN 0 VILLAGE
~~CIFYWelXinaer
D. STREETADDREss13 Reldstone Boulevard ZIP12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGr:-27 13.8. DATE OF BIRTH 03 oj j91R
MONTH DAY ~
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESSNewburgh Sch. 0I5t.
15. PLACE OF BIRTHMountKlsco. New York:
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMERobert Alan BaIf
B. COUNTRY OF BIRTtU SA
17. MOTHER
A. MAIDEN NAMEShsI'MM .JAdA ~pm
B. COUNTRY OF BIRTtU SA
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
ZIP
YEAR
STRE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
A
27~ ~ OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYj)tJrcJ.lF$~
c. LOCATION OF CEREMONY pu1"Cft e S'? 12fII
(CHECK ONE AND SPECIF~' I'lf ~p
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY F J SJ-J. K J } I
CI rr WN
TITLE J a-l-BJ
DATE
N
NAME (PRINT]
SIGNATURE~
DOH-98 (11/98)
J Of) ~
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NAME (PRINT)
SIGNATURE ~