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COUNTY Dutchess
C1TmOWN Wappinger
B~~~~CRT 1368
~5~'l;~R 76
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Bradley S. Roberts
MIDDLE CURRENT SURNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
IJll,ri(;
'7 ~ 1''1- t; ~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Enid Velez
~
I A FULL NAME
11 A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
tL
N
BIRTH NAME. IF DIFFERENT
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Roberts
(OPTIONAL. SEE REVERSE) 089-72-9715
o SOCIAL SECURITY NUMBER
12 RESIDENCE A. N Y B Dutchess
(ST A TEl....., (COUNTY)
C CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFY Wappinger
D STREET ADDRESS 3 Lydia Drive ZIP 12590
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE' 0 YES ri NO
01 /19 /1977
DAY
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 060-74-3442
o SOCIAL SECURITY NUMBER
2 RESIDENCE A. N Y B. Dutchess
(ST A TEI.I' (COUNTY)
C CHECK ONE 0 CITY D TOWN 0 VILLAGE
~~~CIFY Wappinger
o STREET ADDRESS 3 Lydia Drive
3 A AGE 26
ZIP 12590
YES i'1 NO
/ 197
13.B. DATE OF BIRTH
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE' 0
08 / 19
13 A. AGE 25
3B. DATE OF BIRTH
MONTH
DAY
YEAR
YEAR
MONTH
4 EMPLOYMENT
A USUAL OCCUPATION Meteorologist
B. TYPE OF INDUSTRY OR BUSINESS Fleet Weather
5 PLACE OF BIRTH Norwich, New York
(CITY, STATE/COUNTRY IF NOT USA)
6 FATHER
A. NAME Charles Roberts
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Jacqueline Berger
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
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher - Su b
B. TYPE OF INDUSTRY OR BUSINESS Wapp. Schools
IS. PLACE OF BIRTH Arecibo, Puerto Rico
(CITY. STATE.COUNTRY IF NOT USA)
16. FATHER
A. NAME Luis Velez
B. COUNTRY OF BIRTH Puerto Rico
17 MOTHER
A MAIDEN NAME Elaine Rodriguez
B. COUNTRY OF BIRTH U. S. A
lB NUMBER OF THIS MARRIAGE 1
19 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END' (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
B. HOW DID LAST MARRIAGE END' (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? =:J YES 0 NO
10 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
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
18T 0 0 18T 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 a,nd that I declare that no legal i~iment exists
as to my right to enter into the m!lf(ja e state./ "'--." -:;<-- . ._~"V/
21 SIGNATURE OF GROOM ~ ~ ,/,i ...,., .~:::- 22 SIGNATURE OF BRID~'~~'&:::~/~~r
'CURRENT NAME . ~ USE CUR~ NAME ( ...l
23 ~~BNSA~~~~DO~NT~~~O~RN~~y8g~~~~E DATE --ur::>/07/2002
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 CLEflK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Glon J
{ 06/07/2002 TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ / DATE
M~~G~OO r Falls NY 12590 08:41AM 06 08 200 08 06 2002
'-v-l 'PM
STREET STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
~~~sM~~~~g~B~v;Hci'N PTEH~ o~ RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
1 [J CIVIL
A. STATE NEW YORK B COUNTY,o, L-tr: he ~)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 '\.1l"LAGE OF
- \ 3- 0.;)
9 0 OTHER, SPECIFY
29 OFFICIANT ~ Salld rr- 8 ~
NAME (PRINT) eu. "'C:. am z
SIGNATURE ~ ~ ~ L(3. 4crctL
MAILING ADDRESS
q 'Q A~ S0-.4 '\A.. LV .
STREET CITY/TOWN
3D, WITNESS TO CEREM
TITLE
"1J'r\i*-i
'1-/3-U
'i
SPECIFY
W QpP t(f' fctl'~
l)
NAME (PRINT)
SIGNATURE ~