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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Jeffre~o~iIIiam Ch~R~fDRN~ME
9; PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 06 / 09 / 1999' C. DATE LAST MARRIAGE ENDED? / /
MONT':1,.o DAY YEAR MONTH DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
06/09/1999 PouQhkeepsie, Ny l'5 0 1ST 0 0
o 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
and belief that the information I provided is true and that I declare' thaI no legal impediment exists
22. ~IGNATURE OF BRIDE~ '-n1~ Cl.itii;;~ .
~RENT NAME .
DATE 07/24/2009
by New York Domestic
COUNTY Dutchess
CITYfTOWN WappinQer
~~~:~c; 1 368 .
~~~I:~~R 78
I . A. FULL NAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)080 56 6258
D. SOCIAL SECURITY NUMBER --
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUN~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Waopinaer
o STREET ADDRESS 49 Gold Road ZIP 12590.
E. .IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 ~O :
07 /30 /1964
MONTH DAY YEAR
3. A. AGE 44
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Telecommunications
B. TYPE OF INDUSTRY OR BUSINESS Telecommunications
5. PLACE OF BIRTH Rhinebeck, Nv
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Robert Lawrence Chapman
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Carol A. Lewandowski
B. COUNTRY OF BIRTH USA
6. NUMBER OF THIS MARRIAGE 2
DEATH
o
1ST
2ND
3AD
4TH
I duiy swear/affirm, depose and say,
as to my right to enter into the mar
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
30. WITNESS TO CEREMONY
"M"-n~~~() ~dll.E
SIGNATURE~ ~ ~ ~
DOH-98 (0312006)
(I HI::; ::;/"A(;t; J-UH ::;IAIt; u::;t; UIVLYI
Lo
-.J
SUPPLEMENTAL FILE
FROM THE BRIDE
Marcv Fannie Altman
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Chapman
. (OPTIONAL. SEE REVERSE)076_62_8402
D. SOCIAL SECURITY NUMBER
12 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~CIFY WappinQer
STREET ADDREss49 Gold Road
ZIP. 12590
OYE~ '6 NO
;t'962
YEAR
0:
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13.~. AGE 47 3B. DATE OF BIRTH 06 A)9
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION ParaleQal
B. TYPE OF INDUSTRY OR BUSINESS Legal
IS. PLACE OF BIRTH Queens, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Howard .Altman
.B. COUNTRYQFBIRTHU SA
17. MOTHER
A. MAIDEN NAME Audrey F. Kessler
B.COUNTRYoF BIRTHU S A
18. NUMBER OF THIS MARRIA(3E' 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE 'CIVIL ANNULMENT
o 0
DEATH
o
MONTH
YEAR
09
22 2009
CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~;a""V
C. LOCATION OF CEREMONY
(CHECK ONE AN~PECIFY)
o CITY OF l1t'TOWN OF 0 VILLAGE OF
SPECIFY.lI)Qff/l1o ~,<.