147
~. COUNT~ Dutchess
CITYiTOWN Wappinger
DISTRICT 1368
NUMBER
REGISTER 147
NUMBER
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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rudi Bakker
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
I-Iesthf"f E CmL
MIDDLE . ~OI'lRENT SURNAME
11. A. FULL NAME
FIRST
FIRST
ll.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~~r
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER nR~1'lFlRQ
12 RESIDENCEA. N~lnrk" B q~1
C. CHECK ONE 0 CITY o.;rOWN 0 VILLAGE
~~CIFY Fighkill
D. STREET ADDRESS 28 AltA DrlV$ ZIP 12~.oo
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ry NO
13. A. AGE 28 13.B. DATE OF BIRTH McitQ / ~ly 4~i
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York
(STATE)
C. CHECK ONE 0 CITY c1'TOWN 0
~~~CIFY Fishkill
D. STREET ADDRESS 25 AIta Drtve ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r/ NO
17 / ':>7 / 1Q76
MONTH DAY YEAR
B. Dutchess
(COUNTY)
VILLAGE
3. A. AGE IT
38. DATE OF BIRTH
14. EMPLOYMENT
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4. EMPLOYMENT
A. USUAL OCCUPATION Self. EmDloved
B. TYPE OF INDUSTRY OR BUSINESS Estate ManaQ&ment
5. PLACE OF BIRTH Port elizabeth. South Africa
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Johan Hendrik Bakker
B. COUNTRY OF BIRTH SOuth Africa
7. MOTHER
A. MAIDEN NAME Carolina May Et~
B. COUNTRY OF BIRTH South Africa
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
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(2) 0 DEATH
A. USUAL OCCUPATION Ph8rm8ce1ltical~ Sales
B. TYPE OF INDUSTRY OR BUSINESS Pflze.r
15. PLACE OF BIRTH ~~~~:tol1c
16. FATHER
A. NAME VUilliam Francis Cox
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Jucith Fran_ Carter
B. COUNTRY OF BIRTH USA
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
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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1ST
2ND
3RD
4TH
I, being duly sworn, de
as to my right to enter in
21.
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
and belief that the information I provided is true and th
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. SIGNATURE OF BRIDE ~
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23. SUBSCRIBED AND SWORN TO B RE ME
SIGNATURE OF TOWN OR CI CLE DATE
This license authorizes the marriage in New York State auttiorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within 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 Dr subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Gloria
TIME MONTH YEAR MONTH
SEAL SIGNATURE ~- TE 1212'Y?fV\4
'-v-I M~lJicd~ 09-08 AM
STREET C STAT ZIp. PM 12
~~~R~~~Ri~~~ 10~O~~~N:,z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY 1 - ""'-::CIVIL
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS ~ CI'
DATE AND AT THE TIME AND ,.,. ..-
PLACE INDICATED. I J-:> 0;) 90 OTHER, SPECIFY
~~St~~~~T 9~~i) L. SrEiN/fe,~ TITLE r~~ ~rTJGE:
. ()a-.J.. L-. ~~DATE 'It!)" IDS-
I/1';f.t.41f 76/'r'Rd Mt~ J~ !\J 't / )..~J!
clTvrrowN I SlATE
YEAR
24
2004 02
21 2005
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY l>v7UtEQ'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0
VILLAGE OF
If I/Oe f7~t
SPECIFY
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)