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COUNTY Dutchess
CITY/TOWN Wappinaer
~~~~~CRT 1368
~5~I~J~R 152
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Derrick W. Roberts
MIDDLE CURRENT SURNAME
::::> I Po. II:. riLl:. I'tUMDl:.n
(THIS SPACE FOR STATE USE ONL Y)
(}Jtt
i'l, 'IJ~ . [7/
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Debra Guastaferro
~
A. FUll NAME
11 A FUll NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
BIRTH NAME. IF DIFFERENT
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Roberts
(OPTIONAL - SEE REVERSE) 081-72-0996
o SOCIAL SECURITY NUMBER
12 RESIDENCE A New York B Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY 0 Y'OWN 0 VILLAGE
~~~CIFY East Fishkill
o STREET ADDRESS 101 Augusta Drive
12533
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 062-74-9555
o SOCIAL SECURITY NUMBER
2 RESIDENCE A. New York B Dutchess
(STATE) J (COUNTY)
C CHECK ONE 0 CITY 0 "TOWN 0 VILLAGE
~~~CIFY Wappinqer
o STREET ADDRESS 21 Kent Road
12590
ZIP
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE' 0 YES 0 ~o
10 / 12 /1972
MONTH DAY
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VilLAGE' 0 YES 0 ~NO
3 A. AGE 24 38. DATE OF BIRTH 04 / 20 / 197
MONTH DAY YEAR
29
13.B. DATE OF BIRTH
13 A. AGE
YEAR
14 EMPLOYMENT
4 EMPLOYMENT
A. USUAL OCCUPATION Social Worker
B TYPE OF INDUSTRY OR BUSINESS St. Cabrini Home
15. PLACE OF BIRTH Rockland County. New York
(CITY. STATEiCOUNTRY IF NOT USA)
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A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS Baltimore School Of
5. PLACE OF BIRTH New Rochelfe,-New York
(CITY. STATEiCOUNTRY IF NOT USA)
6. FATHER
A. NAME Ronald Roberts
B COUNTRY OF BIRTH Guyana, South America
7 MOTHER
A MAIDEN NAME Eilp.efl Rnri9p.r~
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
(2) 0 DEATH
16. FATHER
A. NAME Vincent Guastaferro
B COUNTRY OF BIRTH Italy
17. MOTHER
A. MAIDEN NAME Tn Icty C:Rfip.rn
8. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
t-
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B HOW 010 LAST MARRIAGE END' (3) 0 DIVORCE
C DATE lAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
8. HOW DID LAST MARRIAGE END' (3) 0 DIVORCE
C DATE lAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
o 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
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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1 5T 0 0 15T 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 marria state. Il" J., ~~
21 SIGNATUREOFGROOM~ 22.SIGNATUREOFBRIDE~ ~C] ~---
USE CURRENT A
11/16/2001
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23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York S groom named above by any person authorized by New York Domestic
Relations Law ~11 to pertorm marriage ceremonies withi 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 CLERK 25 A. SOLEMNIZATION PERIOD BEGINS 25. B ~~6~MA~Z.J111~1~~i~~O
} NAME (PRINT) ~~S~7 .....,..lJ~ TIME MONTH YEAR MONTH DAY
{SEAL SIGNATURE ~ .- - ~~. ,~/;P DATE 11/16/200
~ MAILl2bA~iaa'lebush Rd I a i er Falls NY 12590 AM 11 17 20 1 01 15 200
STREET ITYiT N STATE ZIP 12:4Bv1
I CERTIFY THAT I SOLEMNIZED 26 SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ~
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO DAY YEAR 0 0 RELIGIOUS 1 'CIVIL
DATE AND AT THE TIME AND 2 45- 01
PLACE INDICATED ': PM
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTyPutnam
9 0 OTHER, SPE'C!FY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~'LLAGE OF
TITLE
Vi llaoe .Jllsti r.P.
1:;.:/1/2001
Cold Spring
DATE
SPECIFY