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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Leroy l. Ashley
MIDDLE CURRENT SURNAME
COUNT-,Qutchess
CITYfTOWNWappinQer
~~~~~CR-' 368
~5~I~J~F1f 21
A. FULL NAME
FIRST
a.
N
8 BIRTH NAME, IF DIFFERENT
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONLY)
I
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSIii96-62 7403
o SOCIAL SECURITY NUMBER U -
2. RESIDENCE ANew York B. Putnam
(STATE) (COUNTY)
C CHECK ONE 0 CITY 0 TOwN""O VILLAGE
~~~CIFY Cold SprinQ
D. STREET ADDREss12 Academy Street ZIP 10516
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? "'b YES 0 NO
Au /1971
DAY YEAR
3. A. AGl31
3B. DATE OF BIRTH
05
MONTH
/2i1l
/'1 /' -1
'f)-}jV&'\
u
4. EMPLOYMENT
A. USUAL OCCUPATIONMaintenance
B. TYPE OF INDUSTRY OR BUSINEs~oughkeepsie City School
5. PLACE OF BIRTiHudson. New'"Ycirk .
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Leroy Ashley
B. COUNTRY OF BIRTJJ S A
7. MOTHER
A. MAIDEN NAME Marie r.olemRn
B. COUNTRY OF BIRTHU SA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
L 0 SUPPLEMENTAL FILE
-.J
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
11. A. FULL NAME
FROM THE BRIDE
Rhonda T. John
MIDDLE
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to
as to my right to enter into the marriage state
21. SIGNATURE OF GROOM ~
FIRST
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGEAshley
(OPTIONAL. SEE REVERS Ell 1
D. SOCIAL SECURITY NUMBER f 8-82-5084
12. RESIDENCE iNew York BPutnam
(STATE) (COUNTY)
C CHECK ONE 0 CITY 0 TOWN -6 VILLAGE
~~~cIF..,cold Sprina
D. STREET ADDRESS12 Academy Street zIP10516
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? vb YES 0 NO
13. A AG~6 . 13~. DATE OF BIRTH 07 J.(o US7A
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Teaching Assistant
B. TYPE OF INDUSTRY OR BUSINEs~oughkeepsie City School
15. PLACE OF BIRTtArima Trinidad . . .
(CITY, stATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMrMarcel John
B COUNTRY OF BIRTiTrinidad
17. MOTHER
A. MAIDEN NAM.Fri~l'II I p.wi~
B. COUNTRY OF BIRTiTrinidad
18. NUMBER OF THIS MARRIAGE 1
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
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
o 0 1 ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
ledge and belief that the information I provided IS true and that I declare that no legal Impediment eXists
22 SIGNATURE OF BRIDE ~ g, ()'vt ,,",/1, 9r-:n ~
. ~ENT NAME~
DATE 08/07/2002
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by New York Domestic
MONTH
YEAR
23. SUBSCRIBED AND SWORN TO BEFOR ME
SIGNATURE OF TOWN OR CITY CLERK
This license authorizes the marriage in New York S te of the bride and groom named above by any person authorized
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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)Gloria J.
TIME YEAR
SEAL SIGNATURE ~
'-v-I ~I~t& e Sush Rd 1:19
STREET ZIP
I CERTIFY THAT I SOLEMNIZEO
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
2002 10
06 2002
2B. PLACE WHERE MARRIAGE OCCURRED
STATE NEW YORK B. COUN~
LOCATION OF CEREMONY
(CHECK ONE AND. SPECIFY)
o CITY OF ~OW~ OF 0 VILLAGE OF 'L-
::lr ~_ . ;1a...~
SPECiFy -7' - - . -r-
29. OFFICIANT OE"I/.Jf:'oC'~IIJb eYIfI//I/A L./~ EA/cA
NAME (PRINT) ~. ~ ':l~v TITLE
(7f_~_ /-/ - . -r'. I r 1/t7/a.,;z.
SIGNATURE ~ ~~ J- ?~ . -,.-v DATE / '
MAILING A~RESS J? / "..., 17 '" A . ~ 5/C;
7? d~~/?-t <-r-.c. ~-~.~ oU /d
STREET CITY/TOWN / ~TATE , ZIP
30. WITNESS TO CEREMONY 31. WITNESS T~O EREMONY
NAME (PRINT) ~e_~ Le-\.J-,.)\<", NAME (PRINT) -JA~1
SIGNATURE ~ ~l'lcfi ~ _ kf)1X)\r) SIGNATURE ~
DOH.98 (11/98)