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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Keith W Odums
MIDDLE CURRENT SURNAME
:GJNTY Dutchess
CITY/TOWN Wappinger
~~~~kCRT 1368
~5~I~J~R 97
A FULL NAME
FIRST
Q.
N
B BIRTH NAME, IF DIFFERENT
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 6
o SOCIAL SECURITY NUMBER 084-54-111
2 RESIDENCE A, N Y B, Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY r'i TOWN 0 VILLAGE
~~~CIFY Wappinger
o STREET ADDRESS 71 Brothers Road ZIP 12590
E IS RESIDENCE WITHiN LIMITS OF CITY.OR INCORPORATED VILLAGE? 0 YES '!"5 NO
O? /08/1970
MONTH DAY YEAR
3 A, AGE :1?
3B DATE OF BIRTH
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Lennice M, Johnson
~
4 EMPLOYMENT
A USUAL OCCUPATION Manager
8 TYPE OF INDUSTRY OR BUSINESS Verizon
5, PLACE OF BIRTH Bronx, New Yark
(CITY, STATE/COUNTRY IF NOT USA)
6 FATHER
A, NAME William Odums
B COUNTRY OF BIRTH USA
7, MOTHER
A MAIDEN NAME \ ana Turner
B COUNTRY OF BIRTH USA
NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
11 A FULL NAME
FIRST MIDDLE
BIRTH NAME (MAIDEN NAME) IF DIFFERENT Johnson
C SURNAME AFTER MARRIAGE Odums
(OPTIONAL - SEE REVERSE} 130 70 364')
o SOCIAL SECURITY NUMBER - - "-
12 RESIDENCE A_ N Y B Dutchess
c, CHECK ONE (STAa') CITY i"l' TOWN 0 VILLAGE (COUNTY)
~~~CIFY WappinQer
o STREET ADDRESS 71 Brothers Road ZIP 12590
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 11 NO
02 /03 /1971
MONTH DAY YEAR
CURRENT SURNAME
13A AGE31
13,8 DATE OF BIRTH
B HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
14, EMPLOYMENT
A USUAL OCCUPATION Sales
B, TYPE OF INDUSTRY OR BUSINESS Aventis
15_ PLACE OF BIRTH Port Chester, New York
(CITY, STATE/COUNTRY IF NOT USA)
16_ FATHER
A, NAME Abraham Johnson
B COUNTRY OF BIRTH USA
17 MOTHER
A MAIDEN NAME Cecilia Pride
8 COUNTRY OF BIRTHU SA
18, NUMBER OF THIS MARRIAGE 1
19, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
c. DATE LAST MARRIAGE ENDED?
YEAR
B, HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
(21 C DEATH
MONTH DAY
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 P,GAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
(31 0 ANNULMENT
/ /
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
1ST 0 0 0 0
ffi 2ND D 0 [J 0
'" 3RD 0 0 0 0
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z 4TH 0 0
0
z I, being duly sworn, depose and say, th I impediment exists
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23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNA TURE OF TOWN OR CITY CLERK t-
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law S11 to perform marriage ceremonies within New York State_ THIS LICENSE VALID IN NEW YORK STATE ONL y-
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 J. Morse
{ 0 07/09/2002 TIME MONTH
SEAL SIGNATURE ~ DATE
'-.,-I M~~?8 ebush Rd, W Ing Falls, NY 12590 08:38 ~~ 07
STREET CITY'T WN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26_ SOLEMNIZATION OCCURRED 27, TYPE OF CEREMONY
THE MARRIAGE OF THE PER- I
SONS NAMED ABOVE ON THE TIME MO' DAY YEAR o'iZ RELIGIOUS
~~Z~E ~~glt:T~~E TIME AND 11. -0 A 0 i 2.0 ~2. 9 0 OTHER, SPECIFY
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NAME (PRINT) .
SIGNATURE t-
MAILING ADDRESS L 12
CO t ~ Pi. \C ~ of iv't Co T t;;,J ('b ",)<i.
STREET CITyrroWN
30. WITNESS TO C
TITLEJ:'f."'..,......+ E.C..Lcr
DATE 07!'}..%'l-
NY
YEAR
28. PLACE WHERE MAP,RIAGE OCCURRED
10 CIVIL
A_ STATE NEW YORK B. COUNTY Wvt c.~
STATE
I 04-74-
ZIP
31, WITNESS TO CEREMONY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
",CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY N ~ ~oc.~l--k.
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SIGNATURE t-