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1. A. FUll NAME
~ I '"' I I:. ur I~I:. VV ,un",
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
William Walter Mahlmeister, Jr.
FIRST MIDDLE CURRENT SURNAME
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITYITOWN Wappinger
~~~:~c: 1368
~~~I:~~R 40
.J
L 0 SUPPLEMENTAL FILE
"-
N
B. BIRTH NAME, IF DIFFERENT
FROM THE BRIDE
Marisol Scannell
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENTMarisol Colon
C. SURNAME AFTER MARRIAGE Mahlmeister
(OPTIONAL. SEE REVERSE)598_0 1-4262
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY B. Dutchess
(STATE) J.. (COUNTY)
C. CHECK ONE CJ CITY U TOWN 0 VILLAGE
~~~CIFY Wappmger
D. STREET ADDRESs3H Alpme Dr
11. A. FUll NAME
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)263_4 7 -8817
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinger
D STREET ADDRESS 3H Alpine Dr ZIP 12590
E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 1] NO
04 /24 /1958
MONTH DAY
'Z 12b80
IP
DYES '6 NO
;1'969
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 39 3B. DATE OF BIRTH 06 ))8
MONTH DAY
3. A. AGE 51
3B. DATE OF BIRTH
YEAR
l-
S;
<C
4. EMPLOYMENT
A. USUAL OCCUPATION Engineer
B. TYPE OF INDUSTRY OR BUSINESS Electricity
5. PLACE OFBIRTH Greenwich, Ct
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME William WalterMahlmeister
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Doris Bell Sterling
B. COUNTRY OF BIRTH US A
8. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS Penn Foster
15 PLACE OF BIRTH Manhattan, Ny
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Robert Colon
'B. COUNTRY OF BIRTHPuerto RICO
17. MOTHER
A. MAIDEN NAME Ada Lydia Rodriguez
B. COUNTRY OF BIRTHPuerto Rico
18. NUMBER OF THIS MARRIAGE 3
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DE.e,TH
2 0 U
:: :~~:I:~TM:::II::: E;~~ED~3) t1 DIVORC05 / 0 ;N~tM/ 2~88EATH :: :~~::~~~::::::: E;~~ED~3) r5 DIVOR8E9 )' D1A4NULM/ 2do8 DEATH
MONT"" DAY YEAR MONT~ DAY' ',- YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? [J YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? tJ 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) ICITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 05/19/2008 Poughkeepsie, Ny 0 r1 1ST 09/14/2000 Wnite Plains, NY ~ 0
2ND 0 0 2ND 08/08/1995 White plains, NY 0 r5
3RD 0 0 3RD 0
4TH 0 0 4TH 0
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is tr mpediment exists
as to my right to enter into the j9'lag~tate.
21.SIGNATUREOFGROOM~ ~/ . ATUREOFBRID
USE CURRENT NAME
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) Jo C. Masterson
{TIME MONTH DAY YEAR MONTH
SEAL SIGNATURE ~. DATE 05/'15/2009
"-- -J MAIj.Jt)I,G,.A!;lIDaBE:?S 09:13AM 05 16 2009 0,7 14 2009
-v- LU IVI 01 ush Rd, Wappingers Falls, NY 12590 PM
STREET CITYrrOWN STATE ZIP
~~~R~~RT~~~ IO~O~~~N~ZEE~ 26. SOLEMNIZATiON OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 a RELIGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. ! Jt1 '!: - ;t.:l -() 90 OTHER, SPECIFY
~1r.?:~~~~T L7A E,L'h_A/tD .,(. HVJlVI TITLE ~;9S"-d/{
SIGNATURE. ~ ~~/I~ DATE ~/;l;L./P'7
MAILING ADDRESS ' '
~:~ ~Au7J/ Av/!. CITYf:.:t/J/J/;v~4'J1!.5 ;:"A'"-S -trA~)/
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
o
05/15/2009
DATE
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY (J~aIf"1'$S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF III ViLLAGE OF
SPECIFY ~A;tI'''''/N~~ M~5
NAME (PRINT)
SIGNATURE.
DOH.98 (03/2006)
30. WITNESS TO CEREMONY
31. WITNESS TO C
NAME (PRINT)
SIGNATURE~