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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Charles Wurms
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYrrOWN Wappinger
~~~~~c; 1368
~~~I:~~R 54
1. A. FULL NAME
FIRST
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)060_26_5218
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUN1Y)
C. CHECK ONE 0 CITY '6 TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 10 Central Ave ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES tJ NO
08 /08 /1934
MONTH DAY YEAR
3. A AGE 74
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Retired
B. TYPE OF INDUSTRY OR BUSINESS Engineering
5. PLACE OF BIRTH Brooklyn, New York
(CITY, STATE / COUNTRY IF NOT USA)
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6. FATHER
A. NAME Jack Wurms
B. COUNTRY OF BIRTH Holland
7. MOTHER
A. MAIDEN NAME Alida Wurms
B. COUNTRY OF BIRTH Holland
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
1
(2) 6 DEATH
1994 .
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMEKT
C. DATE LAST MARRIAGE ENDED? 11 / 14 /
MONTH "pAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES CI NO
10, IF PREVIOUSLY DIVORCED OR ANNULLEO, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
YEAR
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
~
FROM THE BRIDE
Roberta Sue Chesney
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Trachtenberg
c. SURNAME AFTER MARRIAGE Wurms
(OPTIONAL - SEE REVERSE)1 07 -30-6872
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A.NY B Dutchess
(STATE).L. (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 10 Central Ave
11. A. FULL NAME
1~O~U
ZIP
MONTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 70 3B. DATE OF BIRTH 10
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY QR BUSINES~Educatlon
15. PLACE OF BIRTH Mannattan, ew York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Sol Trachtenberg
'B. COUNTRY OF BIRTHChlna
17. MOTHER
A. MAIDEN NAME Sylvia Swerdlow
B. COUNTRY OF BIRTHU S A
2
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIOORCE CIVIL ANOULMENT DEtTH
B. HOW DID LAST MARRIAGE END? (3) [j'DIVORCE (3) 0 ANNULMEKT d~~ DEATH
c. DATE LAST MARRIAGE ENDED? 03 / 04 / 2
MONTH .,/JAY ~ YEAR
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/COUN1Y, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
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1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
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 nage st e,
21. SIGNATURE OF GROOM ~
USE cu
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 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
} NAME (PRINT) John C. Masterson
{TIME MONTH YEAR MONTH DAY YEAR
SEAL SIGNATURE ~ . , DATE 06/05/2009
I.- .-.J MAIl.l~ f.ODI)ijE::/S 11: 39AM 06 06 2009 08 04 2009
-v- ~u IVIOOI ush Rd, Wappingers Falls, NY 12590 PM
STREET CITYrrOWN STATE ZIP
~~~R~~RT~~~ IO~O~~~N~~E~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. AY YEAR D~ELIGIOUS
DATE AND AT THE TIME AND AM ... 7'
PLACE INDICATED. 1)-) 0 7;.u;...c.o 90 OTHER, SPECIFY
I . // / J/'
~~:~~~~~ f..-A-.....-It ,f:.A/C/{. tFtt J€ e IJ.-"1./fA/ TITLE & 'l,f)
SIGNATURE~~ ~ DATE XJ-//~
MAILING ADDRE}>S / _./l / I =;z::
D"- J1"tc.)4 '-CC-- ,.//'. ~~b""""JtJ ~ /d- ,-) '-0
STREET I CITYrrOWN / I STATE ZIP
30. WITNESS TO CEREMONY 31. WITNESS TO CEREMONY. ,)'
NAME (PRINT) ( ~,ri ~ NAME (PRINT) ~'j\. fAjl.A?.wv '5>
SIGNATURE~ SIGNATURE~ .A.Jf{ U~,",,'"
DOH.98 (0312006)
DATE
25. B. SOLEMNIZATION PERIOD
ENOS AT MIDNIGHT ON:
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNrU/'(;oJ€....
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF rit'TOWN OF 0 VILLAGE OF
SPECIFY A/€---l...../;',.,/JOr