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COUNTY
"etlY/TOY~
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thomas Keith
FIRST MIDDLE
Ruge
CURRENT SURNAME
I STATE FILE NUMBER
I . (THIS SPAc.E 'E!J STA TE USE ONL Y)
C~ .f\+ ~ I \CD
JJ1{ \ }O\'~ .
I
Dutchess
Wappinger
1368
180
L
-1
U SUPPLEMENTAL FILE
FROM THE BRIDE
Krista Marie
FIRST MIDDLE
A FULL NAME
Raiche
CURRENT SURNAME
11. ~ ~ULL NAME
0-
N
B BIRTH NAME. iF DIFFERENT
alRTH NAME MAIDEN NAME!. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
10PTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER
2. RESIDENCU. New York B Dutchess
ISTATE (COUNTY)
= CITY C TOWN eX VILLAGE
Wappingers Falls
o STREET ADDRESS 11 Church Street
Raiche
100-64-5696
New York B. Dutchess
iSTATE) (COUNTY!
[] CITY ~ TOWN C VILLAGE
Poughkeepsie
STRE~T.\DCRESS 25 Anthony Drive
117-62-8779
- SURNAME~FTER MARRIAGE
OPTIONAL. SEE REVERSE)
, SOCiAL SEC:JRITY NUMBER
12. ~~SiDENCE~.
v. CHECK CNE
AND
SPECIFY
, CHECK CNE
~ND
SPECIFY
ZIP 12590
E. IS RESIDE~CE WITHiN liMITS OF CITY OR INCORPORATED VILLAGE? X:
3B DATE OF BIRTH Sept. / 4
MONTH
ZIP 1260 1
3. A AGE
29
YES [J NO
/ 1971
YEAR
S RESIOE\CE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. .I. ,\GE 28 13.B. DATE OF BIRTH OC t. / 24
MONTH DAY
YES X NO
/1971
YEAR
4. EMPLOYMENT
:JA.....
14. ~'.lPLOYMENT
w
>-
"
>-
rJl
Postal Worker
A USUAL OCCUPATION
B. TYPE OF iNDUSTRY OR BUSINESS U. S. Po s t
5. PLACE OF BIRTH Poughkeepsie,
ICITY STATEcCOUNTRY IF NOT USA)
A. USUAL CCCUPATION Accountant
3. TYPE OF NDUSTRY OR BUSINESS Prime Investments Srvcs
15. ~'-ACEOF5IRTH Mineola, New York
ICITY, STATE COUNTRY iF NOT USA)
Office
New York
6. FATHER
A NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
16. FUHER
William Leonard Raiche
USA
A. ~AME Ronald Ruge
_ ~OUNT~Y CF BIRTH USA
1 ~ ',leTHE=!
.I. \IAIDEN ~AME
Patricia Toni
USA
First
Paskey
Carol Bragg
USA
First
_. CCUNTRY CF BIRTH
8. ,\lUMBER OF THIS MARRIAGE
18. '<UMBE=! CF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
19 ",EVIOUS MARRIAGES
A ~UMBE~ OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVCRCE CIVIL ANNULMENT
DEATH
DEATH
B. HOW DID :.AST MARRIAGE END? 3) CJ OIVCRCE
C. DATE LAST MARRIAGE ENDED?
(31 C ANNULME,<T
/ /
(21 CJ DEATH
- -cw )10 _~s- MARRIAGE END? (3) C DIVORCE 31 = ANNULMENT 2 = :E~~"
JATE -A5T .MARRIAGE ENDED? / /
MONTH DAY YE,4i=
- .IRE ,\NY ~CRMER SPOUSEiS) ALIVE? = YES = NO
JO. ;: ~qEVIOL:S~ v DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFC~MATO"
JATE C' ~E-JREE PLACE iSSUED AGAINST WHC\!
MONTH. JAY YEAR) ICITY. STATE COUNTRY. IF NOT USA) SELF 3POUS:
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE/S) ALIVE? eYES C NO
'0. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWiNG INFORMATION
DATE OF DECREE PLACE ISSUED ~GAINST WHOM
(MONTH. DAY. YEAR) I.CITY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I. being duly sworn. d
as to my right to enter
I
1S-
2t\40
3RC
----
'-'--
prOVided is true and that I declare that no legal impediment i!XIStS
w
en
z
w
o
::i
;1.1\ ~ /7
USE CURRENT NAME ~~
~
23 ~~B:ACT~~~D:;;~~~~OORRN!t'?vBg~:~~E Deputy Town Clerk DATE Sept. 25, 200
This license authorizes the marriage in New York St e of the bride and grcom namea above by any person authorized by New York Domestrc
Relations Law 911 to perform marriage ceremonies within New York State. THIS ...CENSE VALID IN NEW YORK STATE ONLY.
-- If checked. this license is to be used only for the pl.rcose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK , ZO. A. SOLEMNIZATION PERIOD BEGINS
aine Town Clerk .
MONTH DAY
DATE 9/25/00
Wappingers Falls, NY 12590
CITY TCWN STATE :'P .t:-:
27. TY~ OF CERE\'C,,"Y
o 3'RELIGIOUS 1 C C:VIL
Z1 SIGNATUREJF GROOM
~
{ SEAL }
~
25. B. SOLEMNIZATION PERICD
ENOS AT MIDNIGHT ON
NAME (PRIN
YEAR
MONTH
DAY
YEAR
SIGNATURE
MAILING ADDRES-S
PO Box 324,
STREET
I CERTIFY THAT i SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED .A60VE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
9
26
00
11
24
00
9 0 OTHER. SPECFY
28. PLACE WHERE MARRIAGE OCCURRED
A STATE NEW YORK B. COUN.:J)..TCtft!>S
TITLE
If. C 1'7(1 p;r
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
[J CITY OJ .~ TOWN OF ~bE OF
SPECIFY W:lff}~S ~.s
3~ .
NAME (PRINT)
SIGNATURE ~
DOH-96 (1/96)
'l..AME ,PRINTi