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~~~
COUNT',Dutchess
CITY ITOWNVV af:minqer
~~J~~CR'l2.68
~G~~J~Rl 64
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Vincent R" Maldonado
MIDDLE CURRENT SURNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
~it
I~ -';3.t7~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Heather A, O'keeffe
~
1. A. FULL NAME
11. A. FULL NAME
CURRENT SURNAME
FIRST
FIRST
MIDDLE
8. BIRTH NAME, IF DIFFERENT
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Maldonado
(OPTIONAL - SEE REVERSE096 72-4104
D. SOCIAL SECURITY NUMBER -
12. RESIDENCE ANew Y ot"k BDutchess
(STATE). (COUNTY)
C. CHECK ONE 0 CITY 'tJ TOWN 0 VILLAGE
~~~clp,?oughkeepsje
D. STREET ADDRESs120 ChanmngvllIe Hoad tlc
ZIP 12tl9U
vi'
DYESDND
wao
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE;< 04-62 ,., JI 0'"
D SOCIAL SECURITY NUMBER I -0,+ .J
2. RESIDENCE A.New Y Ofk B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY"'O TOWN 0 VILLAGE
~~~CIFY PouQhkeepsie
D STREET ADDRESS 120 Channingville Road 5c ZIP 12590
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"'''o NO
/24 /1977
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AG~1 13.B. DATE OF BIRTH 11 A9
3. A. AGF25
02
MONTH
3B. DATE OF BIRTH
YEAR
MONTH
DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Umempioved
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRT~ronx:, New York
(CITY, STATE/COUNTRY IF NOT UCl"Il
14. EMPLOYMENT
A. USUAL OCCUPATIONMerchandise Handier
B. TYPE OF INDUSTRY OR BUSINESSGap Dlstnbutlon Center
15. PLACE OF BIRTHCo1d Spring, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMETeny O'keeffe
B. COUNTRY OF BIRTM S A
17. MOTHER
A, MAIDEN NAME Kathleen Me ClurQ
!I~ ft
B. COUNTRY OF BIRT~ ~ J.Io.
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
(} 0
6. FATHER
A. NAME Edwin Cruz
B. COUNTRY OF BIRTHU S A.
7. MOTHER
A. MAIDEN NAME Rosie Maldonado
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 (}
DEATH
(}
DEATH
(}
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HDW DID LAST MARRIAGE END? (3) 0 DIVDRCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
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
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
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
t of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ -...t \. . \ \ . ^ ("'f') \~..
~USE CU~ N ME
23. DATE 1 3/2002
This license authorizes the marriage in New York St te of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies withi 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 CL~RK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Glona . Morse
TIME MONTH
SEAL SIGNATURE ~
'-y-I M~trMfcfarebush Rd. 03:11 ~~ 10
STREET ZIP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDI
1ST
2ND
3RD
4TH
I, being duly sworn, depose an
as to my right to enter into the
21. SIGNATURE OF GROOM ~
YEAR
1~
28. PLACE WHERE MARRIAGE OCCUR~
A. STATE NEW YORK B. COUNT
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o "'" 0' 0 mw, 0' ~"o, ~
SPECIFY tiJ~~I.IU. 'iJI!!!d
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~ .