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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~an R /\rmID~SURNAME
CO!JNTY
CITYfTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
Dutchess;
'.fIlappinger
130e
7
1. A FULL NAME
FIRST
"-
N
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 315--23- 2329
2. RESIDENCE A. ~ V an. rtl"'j.ess
~TATE) . (eO!Ml"f11
C. ~H6CK ONE 0 CITY ~OWN 0 VILLAGE
SPECIFY \}\!appinger'
D STREET ADDRESS 799 Old Route 9 A B 11 ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
DYES UlNO
3B. DATE OF BIRTH
3 A. AGE 25
4. EMPLOYMENT
A. USUAL OCCUPATION Direct Care
B TYPE OF INDUSTRY OR BUSINESS Dutchess ARC
5 PLACE OF BIRTH (~~lr,~t1l~ffi'iT USA)
6. FATHER
MON
A NAME Erastus .~gndi Okul
B COUNTRY OF BIRTH Kenya
7. MOTHER
A MAIDEN NAME Pelr-enile Adhiembo Achungo
B COUNTRY OF BIRTH Kenya
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE lAST MARRIAGE ENDED?
o
(21 0 DEATH
(3) 0 ANNULMENT
/ /
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
51 ATE fiLE NUMBEH
(THIS SPACE FOR STATE USE ONL Y)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
UQ~Y A BG~SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~~::LT~~~t~~e~~SE) /\mandi
D. SOCIAL SECURITY NUMBER 081 64 5004
12. RESIDENCE A. "J V B E'luh>hesss
t''lSl'ATE) . ~~/
C. ~H6CK ONE 0 CITY D,JOWN 0 VilLAGE
SPECIFY VVappinger'
D STREET ADDRESS 799 Old Route 9 A B 11 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~O
MoQ1 / 29 /196C
13 A AGE 23
14. EMPLOYMENT
13.B. DATE OF BIRTH
A USUAL OCCUPATION TeaGher Assistant
B TYPE OF INDUSTRY OR BUSINESS Cow/em Of Sacred Heart
15 PLACE OF BIRTH (~~mt!o~ J:~
16. FATHER
A. NAME La\-Jrence \N. 8m.lman
B COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Jennifer K. Talamo
B COUNTRY OF BIRTH U S l\
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
o
(21 0 DEATH
(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
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o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
owl edge and belief that the information I provided is tr
o 0
o 0
o 0
o 0
o legal impediment exists
23. SUBSCRIBED AND SWORN TO BEF E
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law &11 to perform marriage ceremonies within New 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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
21 SIGNATURE OF GROOM ~
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{ SEAL }
'-.,t-l
NAME (PRINT)
NAME (PRINT) ,
SIGNATLlRE. '
DOH-98 (11/98)
DATE
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
08:44~
02
19
2
04
18 2004
ZIP
1~
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF ~LLAGE OF
SPECIFY W 4PP'N~
~.
ZIP
::M;::::;'~~t~
SIGNATURE ~ · .