093
ST ATE OF NEW YORK I STATE FILE NUMBER I
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutchess DEPARTMENT OF HEALTH
CITYfTQWN Wappinger
'~~J~~cJ 1388 AFFIDAVIT, ''LICENSE and
~~~I:J~R 93 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A, FULL NAME J~ A Curtis, JR. 11. A, FUUL NAME Clare Rottka~
FIRST MID LE CURRENT SURNAME FIRST MIDDLE . C RRENT SURNAME
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1~"'1MJ3103
D. SOCIAL SECURITY NUMBER OJ\I"UU"
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~OWN 0 VILLAGE
~~~CIFY Hvde Park
D. STREET ADDRESS 68 lMndmlll Road
ZIP 12801
DYES c1' NO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIULAGE?
3. A. AGE 27 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS WaA). centrI. SOh. 0Ist.
5. PLACE OF BIRTH 1)fta.Mh~.. New York
~FNOTUSA)
6. FATHER
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A. NAME Jay Arden Curtis
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME GAlli ftI dse Sblfer
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
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(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
10. IF PREVIOUSLY DIVORCED ORANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (CITY. STATE/COUNTRY,IF NOT USA) SELF SPOUSE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE CUR
(OPTIONAL - SEE REVERSE) 11 ~ ~ D"749
D. SOCIAL SECURITY NUMBER - - ~Q!..--
12. RESIDENCE A. New York B. Dutchess
(Si'A'tE) (COUNTY)
C. CHECK ONE 0 CITY DIllI!-OWN 0 VILLAGE
~~~CIFY Hyde Park
STREET ADDRESS 68 lMndmlll Road ZIP 12801
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIULAGE? 0 YES CJ'NO
MJI '/g~ /1~JL
D.
E.
13. A. AGE ~
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Wapp. Cntrl. Sch. 0Ist.
15. PLACE OF BIRTH p~~~ N8W Vork
(CITY, S TEiCQUN Y IF OT USA)
16. FATHER
A. NAME Cyril John RoltIcamp
B. COUNlTRY OF BIRTH USA
13.B. DATE OF BIRTH
17. MOTHER
A. MAIDEN NAME Blrbere Jean Denny
B. COUNTRY OF BIRTH USA
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 tJ 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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to
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to
as to my right to enter into the marriage state'
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEFORE M
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 Ne)^' York Domestic
Relations Law ~11 to perform marriage ceremonies within w 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 CITY CLE~K 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Glona J. ~ TIME MONTH
SEAL SIGNATURE ~ -
MAI~ tiCii8bush R AM
'-v-I STREET ZIP 12:31PM oa
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
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29. OFFICIANT
NAME (PRINT)
. SIGNATURE OF BRIDE ~
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED ~
A. STATE NEW YORK B. COUNTYP I.I"'V,- (
NAME (PRINT)
SIGNATURE ~