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COUNTY Dutchess
CITYfTOWN Wappinger
DISTRICT 1368 .
NUMBER
REGISTER 132
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Howard Eugene Patrick, Jr
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Emily Ann Ryder
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Patrick
(OPTIONAL - SEE REVERSE) 074-76-2190
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STATE) oL (COUNTY)
C. CHECK ONE 0 CITY [j TOWN 0 VILLAGE
~~~CIFY Lagrange
D. STREET ADDRESS 25 BushwlcK Kd ZIP 126U;J
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 21 13BDATE OF BIRTH 05 /13 )1'989
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1 00-76-631 0
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY B. Dutchess
(STATE) ~ (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFY WapPin~er
D. STREET ADDRESS 84 rothers Rd
3. A. AGE 24
ZIP 12590
YES ~ NO
/ 1986
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
02 / 28
MONTH DAY
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS Dutchess Community
5. PLACE OF BIRTH Hampton, Virginia
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Howard Eugene Patrick Sr
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Sherri Ann Booth
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
14. EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDU~RY OR. BUSINESS Dutchess Community
15. PLACE OF BIRTH jJougnkeepsle, New YorK
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Michael Joseph Ryder
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Laura Ann Tuthill
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DICfRCE CIVIL ANaULMENT
DE(fH
DEbTH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.' YEAR
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
,.
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) ICITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is tr
as to my right to enter into the mama e S ,
21. SIGNATURE OF GROOM ~
o
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USEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11to periorm 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 CI C ERK . M 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
YEAR
by New York Domestic
,-"-..
{ SEAL }
'-v-'
11
26 2010
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1~CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY.11~< <::
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
SPECIFY lJ 6f1h .5 f' r
SIGNATURE
MAILING AD
e.tLS..
STREET CITYfTOWN
'" WIT"SS W 7f!!'"
NAME (PRINT) /~/1a.e~ jJz;flJIJfl
SIGNATURE ~ :/cdt ~
DOH.98 (09/2009)