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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c:1368
~~~':~~R55
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Terrence Donell Williams
MIDDLE CURRENT SURNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Anissa Marie Smith
MIDDLE CURRENT SURNAME
~
1. A. FUll. NAME
11. A. FUll. NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGEWilliams
(OPTIONAL. SEE REVERS~ 04-72-5453
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ~Y eRutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CIT0"O TOWN 0 VilLAGE
~~CIFY~inger
D. STREET ADORE 1 0 Maloney Rd
ZIp12603
o YESY"D NO
)976
YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEb88 52 1903
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 ClrvYb TOWN 0 VILLAGE
~~CIFY Wappinaer
D. STREET ADDRESS 51 0 Maloney Rd ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YEsY"D NO
08 /14 /1960
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AG~3 3B. DATE OF BIRTH 09 .29
MONTH DAY
3. A. AGE49
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Police Officer
B. TYPE OF INDUSTRY OR BUSINESS Law Enforcement
5. PLACE OF BIRTHBrooklvn, NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Hoover Herbert Williams
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Ethel Evelvn COQer
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATlo~tay At Home Mom
B. TYPE OF INDUSTRY OR BUSINESSStay At Home Mom
15. PLACE OF BIRT~ueens, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAM~rnexx Justin Smith 1\
'B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAME Theresa Rose Rocco
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 1
w
(/)
z
w
o
::i
9. ~~~~~~J>R~FR~h"E<t,~~us MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) tJ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 12 / 09 / 2009 c. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR MONTH DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 12/09/2009 New York. NY 0 ~ 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm. depose and say, that to the best of my knowled e 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 m mage state. . ,,(t,. ~ _ _. . I 17.. (' _ _. . '"-J-Ih
21. SIGNATURE OF GROOM~ ~ (.II...{ ~
USE USE CURRENT NAME
23. ~~':J:-m~~DO~N~~~: J;~A~r:r~E~ BEFORE ME DATE OS/24/2010
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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
n
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DCfTH
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
'-v-I MA~~GIOOD
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DAY
YEAR
MONTH
YEAR
MONTH
2010
07
23 2010
05
25
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVil
A. STATE NEW YORK B. COUNTY L?p~4<'5
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ;( VilLAGE OF
SPECIFY ti/~A"//V~rf~ rA<A5"
TITLE /?A~(?/<
.
DATE b -;;<0 - /0
A'~S I1/l
STATE
0;' JSc..J
SIGNATURE