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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Timothy J.
FIRST MIDDLE
COUNTY
. CITYfTowlll
DISTRICT
NUMBER
REGISTER
NUMBER
Dutchess
Wappinger
1368
165
A. FULL NAME
Gardner. Jr.
CURRENT SURNAME
0-
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York
(STATE)
C. CHECK ONE 0 CITY Xl TOWN 0 VILLAGE
~~~CIFY Eas t Fishkill
D STREET ADDRESS 21 Du an Lane ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY R INCORPORATED VILLAGE' 0 YES ~ NO
/01 /1979
DAY YEAR
096-62-8377
B. Dutchess
,COUNTY)
3. A. AGE
21
Feb.
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Machine Operator
B. TYPE OF INDUSTRY OR BUSINESS . S toneykill Exca.
5. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Timothy J. Gardner, Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Debra Durso
USA
First
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
3. HOW DID LAST MARRIAGE END' 131:: DIVORCE
" DATE LAST MARRIAGE ENDED?
(31 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE?:: YES :: NO
'0 IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) ICITY, STATEfCOUNTRY. IF NOT USA) SELF SPOUSE
11. A. FUUL NAME
I"
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONLY)
I
/~I,~/t)l>
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Rachel V.
FIRST MIDDLE
~
Rhodes
CURRENT SURNAME
B. BIRTH NAME :MAIDEN NAMEi. IF DIFFERENT
27, TYPE OF CEREMONY
o 0 RELIGIOUS
o OTHER, SPECIFY
C, SURNAME AFTER MARRIAGE Gardner
(OPTIONAL. SEE REVERSE) 180-68-3012
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY IX TOWN 0 VILLAGE
;~CIFY East Fishkill
D. STREET ADDRESS 21 Dugan Lane ZIP
E. IS RESIDENCE WITHIN LIMITS OF CI>>8Jl~~WJJ,.E;v1ta~f iOIG
13. A. AGE 20 13,B. DATE OF BIRTH Oct. /20
MONTH DAY
14. EMPLOYMENT
12533
YES ~ NO
/1979
YEAR
A. USUAL OCCUPATION Retail
B. TYPE OF INDUSTRY OR BUSINESS Filene ' s
portchester, New York
(CITY, STATElCOUNTRY IF NOT USA)
15. PLACE OF BIRTH
16. FATHER
A. NAME Frederick Rhodes
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME
B COUNTRY OF BIRTH
Wilma Mej ias
USA
First
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HCW DID LAST MARRIAGE END' (3) C DIVORCE 3) = ANNULMENT 2) = CEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY VE.'R
D ARE ANY FORMER SPOUSE(S) ALIVE? eYES = NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATiON
DATE OF DECREE PLACE ISSUED AGAINST WHOM
,MONTH. DAY. YEAR) CITY. STATEfCOUNTRY, IF NOT USAI SELF SPOUSE
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to the best of my
as to my right to enter into the ma~state.
21. SIGNATURE OF GROOM ~ '-"'
25. B. SOLEMNIZATION PERIOD
ENOS AT MIDNIGHT ON:
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
2, SIGNATURE OF BRIDE ~
- U N E
23. SUBSCRIBED AND SWORN TO BEFORE ME D t T Cl rk S 11 2000
SIGNATURE OF TOWN OR CITY CLERK ~ epu y own e DATE ep t . ,
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 within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
LJ If checked. this license is to be used ani for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
aine H. Snowden, Town Clerk
DATE 9/11/00
NY 12590
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{ SEAL }
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SIGNATURE
MAILING ADDR
PO Box
s
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICAT
10 :30AM
PM
CIVIL
00
11
10
9
12
28, PLACE WHERE MARRIAGE OCCURRED
A.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF
rAscio
