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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jason D Conklin 11. A. FULL NAME
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYITOWN Wappinger
~~~~~c~ 1368
~5~I~J~R 15
1. A. FULL NAME
FIRST
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER
2 RESIDENCE A. N Y
C CHECK ONE (STAgl CITY c:YTOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 6 F Scenic Drive
084-68-6397
B. Dutchess
(COUNTY)
ZIP
12590
I STATE FILE NUMBER I
(THIS SPACE FOR STATE USE ONL Y)
~d .0/b/l~
Lo SUPPLEMENTAL FILE ~
FIRST
FROM THE BRIDE
Marisol E. RodriQuez
MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Conklin
(OPTIONAL - SEE REVERSE) 064 64-0477
D. SOCIAL SECURITY NUMBER -
12. RESIDENCE ANY B Dutchess
c. CHECK ONE (STAgl CITY O~OWN 0 VILLAGE (COUNTY)
~~~CIFY WappinQer
D. STREET ADDRESS 6 F Scenic Drive
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d'" NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
3 A. AGE 26 38. DATE OF BIRTH 11 / 07 / 1 r.:l7 13. A. AGE ?? 13.8. DATE OF BIRTH 11 / 29
MONTH DAY YEAR MONTH DAY
ZIP 12590
YES if NO
/1979
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Sheet Metal
B. TYPE OF INDUSTRY OR BUSINESS Taconic Heating & Cooling
5. PLACE OF BIRTH Pee ks kill , New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Gary Conklin
B COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Phylli~ r.;:!ttllti
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
14. EMPLOYMENT
A. USUAL OCCUPATION Administrative Assistant
B. TYPE OF INDUSTRY OR BUSINESS Bostwick Sales
15. PLACE OF BIRTH Peekskill. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Wilfredo RodriQuez
B COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Miriam Negron
B COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
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
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(21 0 DEATH
C. DATE LAST MARRIAGE ENDED?
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, STATElCOUNTRY, 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
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23. SUBSCRIBED AND SWORN TO B F RE ME
SIGNATURE OF TOWN OR CITY RK ~
This license authorizes the marriage in New York State of the bride and groom named abo
Relations Law 911 to perform marriage ceremonies within New York State, THIS LICENSE VALID I 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
1ST
2ND
3RD
4TH
o
o
o
as to my right to enter into the m
21. SIGNATURE OF GROOM ~
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{ SEAL }
"-v-I
DATE 02/19/200
in er Falls NY 12590
ITYIT N STATE ZIP
27. TYPE OF CEREMONY
02
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
o
o
o
TIME
MONTH
AM
03:32M
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR 0 Ii'! RELIGIOUS
//~ 00::1 "5 - ;z. - .2(;()2 9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY W/;STO,Ef'Tc
C. LOCATION OF CEREMONY ,4s-st/ mjJ TIC'N
(CHECK ONE AND SPECIFY) C nU,eC .."
~ CITY OF 0 TOWN OF 0 VILLAGE OF
jJC€~SKIt.~, /V'j 10566
SPECIFY
~~~t~~9,'~~T REV. VERNON Wk/::Rc/?1~Tl/I)I~t: TITLE
SIGNATURE ~ ..x ~ DATE
MAILING ADDRESS <y" Y'-~
/3/ UN/ON ,4v~ ?EEKSk/lL
STREET CITYITOWN
30. WITNESS TO CEREMONY
NAME (PRINT) '" K
SIGNATURE ~
DOH-98 (11/98)
NY
STATE
f};.e cK 111/1 i 1/;c Il R.
.5~ ? - ,200i?.
ItJ560