051
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and S ,that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the m ri. ge sta . C
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~d~ _ / _ '-?'Ch' /'l.~
I ~ USE'\9URRENT N E =-tT
23. ~::JA~~=~DO~NT~~~O~~ 6'ivBg~~~~E DATE 04/29/2003
This license authDrizes the marriage in te Df the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies with New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is tD be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLER~ 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Glona~. ~orse TIME MONTH
SEAL SIGNATURE ~- TE 04/29/200
'-y-I MAIL~n1irdMebush er Falls NY 12590 AM 04
STREET !TOWN STATE ZIP 12:0aM
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
~~~sM~~~~g~B~V;HJ'N PiHRE TIME MO. DAY YEAR 0 I\Y'RELlGIOUS
DATE AND AT THE TIME AND .*"
PLACE INDICATED. PM OS I 3 0'=3 9 0 OTHER, SPECIFY
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SIGNATURE~~( DATE 5-/4--a6
MAILING AgojlE~ I J ./
)JOfl/trrT/.e ~t-fC? . P"<f' ::rgf'('.e~"!'''1J ~r //777
STREET CITY/TOWN STATE
30. WITNESS TO CEREMONY O. /
NAME (PRINT) r1/J.PIf-eQ .L, /J ~I-~nq
SIGNATURE~ C~ JTtJrTI,. ';f. p~ ~^""'.J-
DOH-98 (11/98)
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Andre Rutland
]
COUNTY Dutchess
CITY/TOWN Wappinger
~~J~~CRT 1368
~5~~J~R 51
1. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
a.
N
8. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 106-52 1450
D. SOCIAL SECURITY NUMBER -
2. RESIDENCE A. New York B. Dutchess
(STATE).t. (COUNTY)
C. CHECK DNE 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 621 Sheafe Road lot 33 ZIP 12601
~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0.... NO
05 / 16 / 196
MONTH DAY YEAR
3. A. AGE 41
38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Grocery Manager
B. TYPE OF INDUSTRY OR BUSINESS Stop N Shop
5. PLACE OF BIRTH Orlando, Florida
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
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A. NAME Walter Rutland
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Loretta Massey
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
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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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STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Nancy L Negron
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Rutland
(OPTIONAL - SEE REVERSE) 069-60-0293
D SOCIAL SECURITY NUMBER
12. RESIDENCE A New York B. Dutchess
(STATE) "" (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY Poughkeep5ie
D STREET ADDRESS 621 Sheafe Road lot 33
12601
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 "'NO
08 / 12 /1972
MONTH DAY YEAR
13. A. AGE
30
13_B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Housekeeper
8. TYPE OF INDUSTRY OR BUSINESS Best Western
15. PLACE OF BIRTH Rockv.iJle Centre, Long Island
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Nicholas Negron
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Constance Di Napoli
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
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 SPOLlSE(S) ALIVE? 0 YES 0 NO
2D. 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
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTyt>u/~he.s
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~TY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY Po (; ~ h fee /.JJ./~
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