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Dutchess
COUNTY Wappinger
CITY ITO",,\)
DISTRICTI..J68
~~~I~~~R 13 1
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Shane M. Johnson
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
oe1'~{
1/)
1 .-'1 I'~ i '~l
('I ~ :)' " ~l
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Diane A. Rood
~
1 A. FULL NAME
11. A FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE J 2" A ,c2985
(OPTIONAL. SEE REVERSE' u-'t'Q-
D. SOCIAL SE~~~lll.f&Er\ uutcness
2. RESIDENCE A. (STATE).,j B. (COUNTY)
C. ~H6CK O~appm~'ef 0 TOWN 0 VILLAGE
SPECIFY 93 Widmer Road 12590
D. STREET ADDRESS ZIP
.,.
E IS R~1NCE WITHiN LIMITS OF CITY OR INCORPORATE~~LAGE? ~O 0 YES .H-.~
3. A. AGE 38. DATE OF BIRTH ~ ~
MONTH DAY YEAR
4. EMPLOYMENT .
Town Highway Department
A. USUAL OCCUPATION i Of" 10.'" I
own rouQIIl\eeps e
8. TYPE OF IND~TRY ~iUSINESS N rk -
5. PLACE OF BIRTH oug eepsle, ew YO
(CITY, STATE/COUNTRY IF NOT USA)
B BIRTH NAME (MAIDEN NAME), I; DifFERENT
Jonnson
C S~~~~o\-;rr~~~t~~e~~sE082-52-8248
o SOCIAL Sli.(:iJRITY ~}\BEe_
New YOrK Dutcness
12. RESIDENCE A B.
(STATE)" (COUNTY)
C. CHECK Q~ 0 CITY 0 TOWN 0 VILLAGE
AND wappinger
SPECIFY 93 Widmer Road
D. STREET ADDRESS
6. FATHER
Evan Johnson
A. NAME U 5 A
B. COUNTRY OF BIRTH
'"
E. IS R~'NCE WITHIN LIMITS OF CITY OR INCORPORATmLLAGE? '1 0 Y~S,.,~ NO
13. A. AGE 13.8. DATE OF BIRTH ~ 7 ~ 5
MONTH DAY YEAR
14. EMPLOYMENT c;:: t
......ecre ary
A. USUAL OCCUPATION R If FI t
000 sons
8. TYPE OF IND'8'TRY m~USINESS
15. PLACE OF BIRTrCoug eepSle, New YOrk
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
N ME Everett Rood
A. A t1 S :A:
B. COUNTRY OF BIRTtr
7 MOTHER Bets Dunkly
A MAIDEN NAME J'3 A
B. COUNTRY OF BIRTH :3
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI,RCE CIVIL AlfULMENT
17. MOTHER .
A. MAIDEN NAMEAhce Starr
B. COUNTRY OF BIRT~ S ~
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DffoRCE CIVIL A~ULMENT
DWH
DftTH
-
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVO'f2 (3) 1)fNULMEN20tff DEATH
C. DATE LAST MARRIAGE ENDED? ..J / /
MON~ 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
,,(~QWjI,J;Wi..~1;J\.fll.. J<;:rIl,~TATE/COUNTR;(,~F NOT.~Al.._ S~F SPOUSE
ST11/t!;J/I::Itn t"ougn~eepsle, l''leW TOr~
1 12104/2001 Puughkeepsie, New York 0 ,!II 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I, being duly sworn, depose and say, t e and belief that the information I provided is e and that I ~ tha/t no .Ieg
as to my right to enter into the marria ~
21. SIGNATURE OF GROOM ~ . . SIGNATURE 0
23. SUBSCRIBED AND SWORN TO BEFORE ME USE CURRENT NAME 08/16/2002
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within Ne 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 Wo'tM'J. Morse 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
YEAR
MONTH DAY
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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{ SEAL }
"-v-/
YEAR
MONTH
YEAR
08/16/2002
E
r Falls, NY 12590
2002 10
15 2002
ZIP
STATE
27. TYPE OF CEREMONY
o ~L1GIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNTY i)/tf~
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY !J )t1-j} j} " ru; e;-
I , ,-;
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
10 CIVIL
29. OFFICIANT
NAME (PRINT)
fJ J2. / e 'S -j-
r;-~/- a.t
tft.5;,L
TITLE
DATE
NAME (PRINT)
SIGNATURE ~
DOH.98 (11/98)
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) .?
SIGNATURE ~