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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c; 1368
~~~I;J~R 46
~ I A I t: Ur- Nt: VV T UMI'\
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Casey Thomas Lorenz
MIDDLE CURRENT SURNAME
FIRST
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kimberly Ann West
MIDDLE CURRENT SURNAME
.-J
1. A. FULL NAME
11. A. FULL NAME
FIRST
0.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Lorenz
(OPTIONAL - SEE REVERSEl()90-72-3305
D. SOCIAL SECURITY NUMBER
12 RESIDENCE A.NY B. Dutchess
(STATE) ~ (COUNTY)
C. CHECK Ot!!' 0 CITY W TOWN 0 VILLAGE
~~~CIFY t-'ougnKeepsle
D. STREET ADDRESS 1 C Hudson Harbour Ur.
o YES~ NO
)'984
YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)113_7 6-1586
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK DNE 0 CITY '6 TOWN 0 VILLAGE
~~~CIFY pou,hkeepsie
o STREET ADDRESS C Hudson Harbour Dr.
1~bU1
ZIP
3. A. AGE 25
12601
ZIP
YES tJ NO
/1984
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE25 3B. DATE OF BIRTH 01 JJ7
MONTH DAY
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
03 /21
DAY
38. DATE OF BIRTH
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINEl?S Education
15. PLACE OF BIRTH Hampsteaa, Ny
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard John West
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Julie Anne Olsson
B. COUNTRY OF BIRTHU S A
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIOORCE CIVIL ANOULMENT
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
DEdTH
...
:>
ct
4. EMPLOYMENT
A. USUAL OCCUPATION Assistant Coach
B. 1YPE OF INDUSTRY OR BUSINESS Marist College
5. PLACE OF BIRTH New Rochelle, Ny
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Ralph Francis Lorenz
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Donna Lynn Wright
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
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. . - YEAR
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. 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
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) (CITYICOUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swe!ir/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is true a
as to my nght to enter Into the mama estate.
21. SIGNATURE OF GROOM ~
o 0
o 0
o 0
o 0
.:;enl exists
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
Relations Law ~11 to 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 CITY oh RK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)
TIME MONTH YEAR
SEAL SIGNATURE ~
'-v-I MAI~~G~p 10:36AM 05
STREET PM
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE
by New York Domestic
MONTH
YEAR
07
21 2009
23
2009
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY5Jr~tk::-
~~-b'R
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF cfuwN OF 0 VILLAGE OF
SPECIFY '5 'i"'fI. rr-h-t-o~ ,...:)
ZIP