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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Benjamin Jeffrey Buchalter
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
DISTRICT1368 .
NUMBER
~~~~;~R43
1 . A FULL NAME
FIRST
0..
N
B. BIRTH NAME. IF DIFFERENT
I
I
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEb55_68_1871
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A NY B. Dutchess
(STATE) J... (COUNTY)
C. CHECK ONE 0 CITY'U TOWN 0 VILLAGE
~~~CIFY WapPin~er
D STREET ADDRESS 51 Scarborough Lane
3. A. AGE 39
12b9U
ZIP
YES ....0 NO
/1969
YEAR
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Alison Judith DaMore
~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
05 /27
DAY
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Business Owner
B. TYPE OF INDUSTRY OR BUSINESS Metric Halo
5. PLACE OF BIRTH Manhasset, New York
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Stuart Norman Buchalter
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Ilene Pamela Markoe
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
11. A. FULL NAME
CURRENT SURNAME
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
FIRST
MIDDLE
(3) 0 ANNULMENT
/ /
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
o
o
o
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Buchalter
(OPTIONAL - SEE REVERSE052 -68-3211
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A.NY BDutchess
(STATE).L (COUNTY)
C. CHECK Q~. 0 CITY U TOWN 0 VILLAGE
~~~CIFY wappinger
01 A ::;caroorough Lane 12590
D. STREET ADDRESS ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE35 3B. DATE OF BIRTH 10 )1'6
MONTH DAY
14. EMPLOYMENT .
A. USUAL OCCUPATION Development Director
B. TYPE OF IND4.fiTRY 011 \lUSINESS.AIZhelmers ASSOC.
15. PLACE OF BIRTHt-'ougnKeepsle, New YOrK
(CITY, STATE / COUNTRY IF NOT USA)
....
Y)9730
YEAR
16. FATHER
A. NAME Lewis David DeMore
'B. ;COUNTRY'OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Marcia Lynn Thompson
B. COUNTRy,oF BIRTHU S ~
1B. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D~ORCE CIVIL A~ULMENT
DID. TH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
~ YEAR
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
o
o
o
1ST
2ND
3RD
o
o
o
o
o
o
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23. SUBSCRIBED AND SWORN T /AFFIRMED BEFORE
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and grool'J1 named above by any person authorized
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
{SEAL SIGNATURE ~DATE 05/18/2009 YEAR
'-.t-I MA~5GlOWcraf~ ush Rd, Wappingers Falls, NY 12590
STREET CITYrrOWN STATE ZIP
~~~R~~RT~~~ ~~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 MlELlGIOUS
DATE AND AT THE TIME AND ~ ,~.
PLACE INDICATED. PM Q 9 0 OTHER, SPECIFY
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TITLE
DATE
30. WITNESS TO C~EMONY Tl1 ai:;be ~ I ~
NAME (PRINT) ~~o..y oly~ J. ... Yl "-La
SIGNATURE~ ~ rnll~M1..JL
/.(
by New York Domestic
YEAR
07
17 2009
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~~~Atw J
~ ,2tXJ1 I{-
ST TE ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) ~05.G~~. ~
SIGNATURE~ ~~
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY '1-; ~~ k.', it