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Dutchess
COUNTY Wi ppI
II n r
CITYfTOWfi,. go
DISTRICT ',368
NUMBER 24
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
\Mlliam Thomas Rose
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Michele Velazquez
t A. FULL NAME
1 t A. FUll NAME
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME),IF DIFFERENT Fried
C. SURNAME AFTER MARRIAGE Rose
(OPTIONAL. SEE REVERSE) 11 D-64-857 4
D. SOCiAL SECI!RjTY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE)'; (COUNTY)
C. CHECK ON~ 1:1 &!..ll G. TOWN 0 VILLAGE
~~CIFY t"ougn"v.;;psIe
D. STREET ADDRESS 89 Marple Roaa t:X1.
YES r!f NO
)t965
YEAR
FIRST
MIDDLE
CURRENT SURNAME
CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) t9)->>4S16
2. :~S~::~~~ :ECU~e;~~rk B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE P Clhr;:lTC TOWN 0 VILLAGE
AND OUg lime e
SPECIFY 89 M ... R d ~
Sf ...0 OIl IO;J\...
D. STREET ADDRESS ZIP
E. is RESI~~CE WITHIN LIMITS OF CITY OR INCORPORATED V~GE? ~
3. A. AGE 3B. DATE OF BIRTH / 1
MONTH DAY
4. EMPLOYMENT P .iAl"ll S .
A. USUAL OCCUPATION ro..- upeMsor
B. TYPE OF INDUfiiX.Q!3.,qU~tlIESS 0 C S Industtles
5. PLACE OF BIRTH ,~ya~ Nt!JIN York
(CfTY, STATE/COUNTRY IF NOT USA;
6. FATHER \MIl' J R
A. .NAME lam ames ose
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Maude Conklin
B. COUNTRY OF BIRTH U ~A
B. NUMBER OF THIS MARRIAGE
12603
ZIP
12603
.,.
YES 0 llCl.
/1~3
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR iNCORPORATED VILLAGE? 0
13. A. AGE 39 13.B. DATE OF BIRTH 05 /18
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Bookkeeper
B. TYPE OF INDU~~Y Oli B-"~H~ESS "'nee cnopper
15. PLACE OF BIRTH Mannauan, New YOne
(CfTY, STATElCOUNTRY IF NOT USA)
16. FATHER
A NAME \Mlliam D. Fried
B: COUNTRY OF BIRTH uSA
17. MOTHER
A MAIDEN NAME Carmen Maria Graulau
B: COUNTRY OF BIRTH Puerto Rico
lB. NUMBER OF THIS MARRIAGE 4
DE~
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~RCE CIVIL AN'tSLMENT
.,.
B. HOW DID LAST MARRIAGE END? (3) 0 DIVOR63 (3) 0 ffULMENT ~ 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
(~1'~ G()Sllen~E1~~TRY, IF NOT USA) SELF SPO~
06I'0I1~ Goshen, NY
03f17flOO:) Poughkeepsie, N Y
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVOfE CIVIL ,AN'liLMENT
-"
B. HOW 010 LAST MARRIAGE END? (3) 0 DIVOR'08 (3) 0 raULMENT 2til1 DEATH
C. DATE LAST MARRIAGE ENDED? / /
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
(~'~~~ drangeTEOum;;;FttfVSA) SELF SPO~~ 1ST
o 2ND
o 3RD
o 4TH
nd belief that the information I provided is lru
DOH
21. SIGNATURE OF GROOM ~
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
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.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CI~TbWK J 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)
SEAL SIGNATURE ~
'-v-' MA2fJ'
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
STATE NEW YORK B. COUNTY.PI./rc.H~
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY B~t:~/:E..
~
1M
TREET CITYfTOWN
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