135
o
(})
LO
N
.....
.::r.
....
o
)-w
....
~~
Q)
Z
J!l
.... CO ~
zLL :;:
~~ <(
~Q) c
5c:~ii:
~'-:5 u.
~ ~ <(
g~~
~>g
.... >-
'" t:
Ci-Cu
lJ!ro
wO
~a::
a:
~32
::;0
:5(9
w
~.....
~(I')
;::
a:
w
u
w
a:
w
I
:;;
'"
'"
w
a:
o
o
<(
>
...
li
w
a.
'"
a:
w
'"
::;
::>
z
o
z
<(
....
w
w
a:
....
Ul
~:i:~ W
tu ~ ~
a: ~ <(
ti; S
::J W 0
::; ...J_
!z g u.
<( ... i=
~ 0 a:
{'; ~ W
Iii 0 0
b '"
z ;!:
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~~T 1368
~3~~J~R 135
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Frfwin n RII /tp
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
$let
I) II
/ C - ~. t If,
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
M'iWJE;8 C Knigl3tRENT SURNAME
..J
1. A. FULL NAME
11. A. FULL NAME
FIRST
0-
N
8 BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER ORR-n8-0~~
12. RESIDENCE A. N~~T~ nrk B. ~~~
C. CHECK ONE 0 CITY EY TOWN 0 VILlAGE
AND W .
SPECIFY apprngf!r
D. STREET ADDRESS 31 Gold Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r!!! NO
13. A. AGE 25 13.8. DATE OF BIRTH M~~t / ql. ,/.j~,?
14. EMPLOYMENT
A. USUAL OCCUPATION Rf!tFlil MFlnFlgpr
B. TYPE OF INDUSTRY OR BUSINESS John Urban
15. PLACE OF BIRTH Lona Island,.,\ Nf!W York
(CITY,~TATE/COUNTHY IF NOT USA)
16. FATHER
A. NAME Willie Knight
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Ri~nr:~ P~lnw
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
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 061-76-1892
2. RESIDENCE A. New X ork B. DMtchess
(STAT ) I UNTY)
C. CHECK ONE 0 CITY I!! TOWN 0 VILLAGE
AND W .
SPECIFY apprnger
D. STREET ADDRESS P. O. Box 587
ZIP 12590
OYES~NO
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 24 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Assistant Manager
B. TYPE OF INDUSTRY OR BUSINESS Woodworker's Warehouse
5. PLACE OF BIRTH Bronxville. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Edwin Del Valle
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Nancy Vf!le7
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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 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
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
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
w
en
z
w
o
::i
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 UH 0 0
n wle ge and belief that the in/ormation I provided is true and that I declare thl}t no legal impediment exists
22. SIGNATURE OF BRIDE ~~~__ Z. -~
U~~E
23 ~~BJACT~~~DO~~~~';:~~N6~)lg~':~E DATE 08/26/2002
This license authorizes the marriage in e 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) Glo, (Ia J Morse
TIME MONTH
SEAL SIGNATURE ~ '; DATE 08/26/2002
'-v-I M~'Mf8at~ ush Rd, Falls NY 12590 02:57 ~~ 08
STREET S ATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZAT OCCURRED 27. TYPE OF CEREMONY
~~~sM~~~~g~B~V~~N P.fHRE TIME MO. DAY YEAR 0 ~'GIOUS
DATE AND AT THE TIME AND 1
PLACE INDICATED. I) O-l 9 0 OTHER, SPECIFY
J;,
21. SIGNATURE OF GROOM ~
YEAR
2B. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY )"ft'j,.(-,f"
TITLE
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
DATE
o CITY OF ~ TOWN OF Q VILLAGE OF
WRPfJ,'JiGGR.
SPECIFY
NAME (PRINT) ,
SIGNATURE ~
DOH-98 (11198)