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COUNTyDutchess
CITY/TOWN WapDinaer
~~~~~CRT1368
~5~I~J~R9
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Durward N. Entrekin. JR.
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
(}J}"t
J A3 'l),~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Janet J. Caballero
MIDDLE CURRENT SURNAME
~
A. FULL NAME
11 A. FULL NAME
FIRST
FIRST
a.
;:;
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Entrekin
(OPTIONAL - SEE REVERSE)"." "86-3918
D SOCIAL SECURITY NUMBER U't<f-
12. RESIDENCE ANew York sDutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY !l TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D STREET ADDRESJi22 Chelsea Cay ZIP 12590
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORpORATED VILLAGE? 0 YES ~ NO
13. A AGE~7 13.B. DATE OF BIRTH nR AlR ~f\4.
MONTH DAY YEAR
BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEn52 74-3842
D SOCIAL SECURITY NUMBER ~ -
2 RESIDENCE A. New York B Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY -6 TOWN 0 VILLAGE
~~~CIFY WapDinper
D STREET ADDREss622 Chelsea Cay ZIP 12590
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"'tJ NO
/71 /1~5fl
DAY YEAR
3 A. AGE4~
17
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Secretary
B. TYPE OF INDUSTRY OR BUSINESsManpower
15. PLACE OF BIRT~hiliRDines
(CITY, STATE/COUNTRY IF NOT USA)
16, FATHER
A. NAMEAlfredo Caballero
B. COUNTRY OF BIRT~hilippines
17, MOTHER
A MAIDEN NAME Gracia Melicor
B. COUNTRY OF BIRT~hilippinp.s
18, NUMBER OF THIS MARRIAGE 2
3B, DATE OF BIRTH
4 EMPLOYMENT
A USUAL OCCUPATION College Professor
B. TYpE OF INDUSTRY OR BUSINESS Mount Saint Mary College
5 PLACE OF BIRT~thens, Georaia
(CITY, STA'ECOUNTR'f'lF NOT USA)
6 FATHER
A, NAME Durward Entrekin
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Marilyn Folsom
B. COUNTRY OF BIRTH I J S A
8 NUMBER OF THIS MARRIAGE 2
DEATH
19, pREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0 0 1 0
B HOW DID LAST MARRIAGE END? (3)'6 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B HOW DID LAST MARRIAGE END? (3) ti DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C DATE LAST MARRIAGE ENDED? 09 / 19 /2001 C DATE LAST MARRIAGE ENDED? 07 / 17 /1998
MON~1j; DAY YEAR MONTH DAY YEAR
o ARE ANY FORMER SpOUSE(S) ALIVE? "rJ YES 0 NO D. ARE ANY FORMER SpOUSE(S) ALIVE? i1 YES 0 NO
10 IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST O~/1~/,nn1 Pnllghkppp~ip, Npw Ynrk 0 ~ 1ST 07/17/1~~8 Ath:mtR, G.porgia c -tJ
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 tD enter into the marr' state, ",11, J ~. ~vr
21 SIGNATURE OF GROOM ~ :!.., 22 SIGNATURE OF BRIDE ~ ~
USE CURRENT NAME
23 ~~NSf:~~~D~N-?O~;-;;O~~ 6~yBg~~~~E DATE 01/15/2002
This license authorizes the marriage in New York ate of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies with New York State, THIS LICENSE VALID IN NEW YORK STATE ONLY,
C 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 25 B. ~~6~MA~Z~,bl~I~~i~~D
{ } NAME (PRINT) Gloria J Morse TIME MONTH YEAR MONTH DAY
SEAL SIGNATURE ~. -' r .
MAILING ~DDRESS /' . . AM
'-.,,-I ZIP 12:21 PM 01 16 2002 03 16 2002
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YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICA TED
STATE
27 TypE OF CEREMONY
o ~ElIGIOUS
9 0 OTHER, SpECIFY
C, LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ILLAGE OF
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A, STATE NEW YORK B COUNTY PLt+Ii4~
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
7:a; ~
TITLE
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Z.s ) ZOO L.
}OS-Z.
ZIP
31, WITNESS TO C~ONY
NAME (PRINT) K I)J~H-tq~, e
f1c3~ a-...€
SpECIFY l! ~ cr'\-'\
?~~
NAME (PRINT)
SIGNATURE ~
DOH-9B (11/98)
SIGNATURE ~