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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Nicholas D. Milton
CURRENT SURNAME
COUNTY DutcheSS
CITYn-OWN. Wappinger
DISTRICT 1368
I~UMBER
~5~I~J~R 13
1. A. FULL NAME
FIRST
MIDDLE
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl - SEE REVERSE) 07n~n_.8440
D. SOCIAL SECURITY NUMBER U'"UU""
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappin~r
D. STREET ADDRESS 2419 A Route 9 0
E.
ZIP 12590
IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
08 /19 /1970
MONTH DAY YEAR
3. A. AGE 34
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Driver
B. TYPE OF INDUSTRY OR BUSINESS TrensDOrtetlon C. P. L
5. PLACE OF BIRTH W'llte PlaIns. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Georae Nicholas Milton
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Jill ~8~ Tortor,
B. COUNTRY OF BIRTH Canada
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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
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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
MiQdalia RodriQUez
MIDDLE CURRENT SURNAME
-.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Milton
(OPTIONAL. SEE REVERSE) 07D58-0092
D. SOCIAL SECURITY NUMBER U"
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY [JI"TOWN 0 VILLAGE
AND W .
SPECIFY aPPlnQer
D. STREET ADDRESS 2419 A Route 9 0 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r5 NO
13. A. AGE 31 13.8. DATE OF BIRTH 11 /08 A973
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION FamilY SUDDOrt Worker
B. TYPE OF INDUSTRY OR BUSINESS O. C. H. F.
15. PLACE OF BIRTH Manhattan. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Juan Rodriauez
B. COUNTRY ~F BIRTH PUerto RIco
17. MOTHER
A. MAIDEN NAME Merit' ~i"Jdrlgu.
B. COUNTRY OF BIRTH Puerto Rica
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
knowledge and belief that the information I provided is true and t
SIGNATURE OF BRIDE~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York Stat of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within w York Stale. 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
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{ SEAL }
'-..-'
NAME (PRINT)
TIME
MONTH
YEAR
0211812005
AM
02:50PM
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY !Jrl'X)clYJI
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
Itl"tITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY BL'~bw-, t!.~
02
ZIP
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TYPE OF CEREMONY
o ~ELlGIOUS
9 0 OTHER, SPECIFY
,0 CIVIL
TITLE
DATE
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) VI
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STATE