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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Danny Me Bride
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYITOWN Wappinger
~~~~~CRT 1368
~~~'~J~R 109
1 A FUll NAME
FIRST
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BIRTH NAME, IF DIFFERENT
::i I A I t: t-ILt: NUMt:H:H
(THIS SPACE FOR STi. TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Darlene Perry
MIDDLE CURRENT SURNAME
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C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 078 58 3004
o SOCIAL SECURITY NUMBER --
2 RESIDENCE ANY B Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY 0 TOWN I!f VILLAGE
AND . F II .
SPECIFY WapPJngers a s
o STREET ADDRESS 42 N. Gilmore Blvd.
ZIP 12590
t1 YES 0 NO
E IS RESIDENCE WITHiN LIMiTS OF CITY OR INCORPORATED VilLAGE'
3 A AGE 36 38. DATE OF BIRTH
4, EMPLOYMENT
A. USUAL OCCUPATION Resident Manaaer
B, TYPE OF INDUSTRY OR BUSINESS Anderson School
5, PLACE OF BIRTH Orlando, Florida
(CITY, STATE/COUNTRY IF NOT USA)
6 FATHER
A, NAME Unknown
B COUNTRY OF BIRTH USA
7, MOTHER
A MAIDEN NAME Evelyn Willis Me Bride
B, COUNTRY OF BIRTH USA
8, NUMBER OF THIS MARRIAGE 2
9 PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
o
11 A FULL NAME
FIRST
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE Perry
(OPTIONAL. SEE REVERSE) 078 60 551
o SOCIAL SECURITY NUMBER --4
12, RESIDENCE A. N Y B, Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY 0 TOWN rY VILLAGE
~~~CIFY Wapp;naers Falls
D STREET ADDRESS 42 N. Gilmore Blvd. ZIP 12590
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE' dYES 0 NO
07 /28 /;973
MONTH DAY YEAR
13 A, AGE 28
13,8. DATE OF BIRTH
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B HOW DID lAST MARRIAGE END' (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C DATE LAST MARRIAGE ENDED? 04 / 24 / 2000
MONT'1; 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
1ST 04/24/2000 Goshen, New York 0 d
2ND D 0
3RD D 0
14, EMPLOYMENT
A USUAL OCCUPATION Child Care
B, TYPE OF INDUSTRY OR BUSINESS Self-employed
15, PLACE OF BIRTH Brooklyn, New York
(CITY, STATE/COUNTRY IF NOT USA)
16, FATHER
A NAME Roy Lee Perry
8. COUNTRY OF BIRTH USA
17, MOTHER
A, MAIDEN NAME Adrianna Stevenson
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
DEATH
o
8. HOW DID LAST MARRIAGE END' (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(21 D 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
DA TE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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23 SUBSCRIBED AND SWOf-lN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law Sll to perform marriage ceremonies within 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 CLE.RK 25. A SOLEMNIZATION PERIOD BEGINS
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DATE
by New York Domestic
TIME
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON
MONTH
YEAR MONTH DAY
YEAR
DATE 07/17/2002
d, W ppinger Falls, NY 12590
CITY/TOWN STATE
27, TYPE OF CEREMONY
o il RELIGIOUS
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
7 - ;J.t1- tJ~ 9 D OTHER, SPECIFY
TITLE
--"
DATE
SIGNATURE ~
DOH-98 (11/98)
AM
02:47 PM
15 2002
07
18
200 09
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY Llb76Yd"S'5
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFyWA',p'/~;('f h.4AS
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7-?t:>-P;L
A/l
NAME (PRINT)
SIGNATURE ~