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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Keith M. TeeQarden
MIDDLE CURRENT SURNAME
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the'~/' . . 0' r1 'mg' . (') h.. -4--",
21 SIGNATURE OF GROOM ~ / 7'-" 22. SIGNATURE OF BRIDE ~ J. U"lA J" Q..... K(Jl.m.ll..M /
SE URRENT NAM " U E CURRENT NAME -
23 SUBSCRIBED AND SWORN TO BEFORE ME 07/01/2002
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 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 L1rr~ J. M 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT
_ YEAR MONTH DAY
SEAL SIGNATURE ~
'-v-' MA~~~Wjrebus 200 08
STREET STATE
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICA TED
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~CRT 1368
~~~I~J~R 92
A FULL NAME
FIRST
"-
N
BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)057 -68-9664
D SOCIAL SECURITY NUMBER
2 RESIDENCE A. North Carolina B Wake
(STA.1i') (COUNTY)
C CHECK ONE 1:J CITY 0 TOWN 0 VILLAGE
~~~CIFY Raleigh
D STREET ADDRESS 5316 Seaspray Lane
ZIP 27610
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
09 / 02 / 197
YEAR
3 A. AGE 24
38. DATE OF BIRTH
MONTH
DAY
UJ
>-
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U1
4. EMPLOYMENT
A. USUAL OCCUPATION Mortgage Broker
B TYPE OF INDUSTRY OR BUSINESS N. C. Mortgage Funding
5. PLACE OF BIRTH New Rochelle, New York
(CITY, STATE/COUNTRY IF NOT USA)
6 FATHER
A NAME Richard Francis Teegarden
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME PeQQY Ann Gardner
B. COUNTRY OF BIRTH USA
8 NUMBER OF THIS MARRIAGE 1
9 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
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
o ~ELlGIOUS
9 0 OTHER, SPECIFY
DATE
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
<:::'c. \ l eH-C1
.A~~
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
~j1it
7 ,; ~-'C/~
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Annmarie Roberto
~
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Teegarden
(OPTIONAL - SEE REVERSE) 099-70-1628
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. North Carolina B Wake
(ST AJJ) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY Raleigh
o STREET ADDRESS 5316 Seaspray Lane ZIP 2 (61 U
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
01 /23 /1976
13 A. AGE 26
13.8. DATE OF BIRTH
MONTH
DAY
YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B TYPE OF INDUSTRY OR BUSINESS MllIbrook t:lementary
15. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A NAME Joseph Anthony Roberto
B. COUNTRY OF BIRTH USA
17. MOTHER
A MAIDEN NAME Kim Hai Nguyen
B COUNTRY OF BIRTH Viet Nam
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI'QRCE CIVIL AN5ULMENT
DEer
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENOED?
(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
25 B SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON
YEAR
30 2002
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTy.tV/LiteS'
c~a/"U P~/~r
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ]lc' TOWN OF 0 VILLAGE OF
:;::, 'Sft K t /I
dvl 7
IV
2 (II ;nn?
0(11
SPECIFY
STATE
31.
SIGNATURE ~