010
+
I-
Z
W
00
W
Ql
o
..J
::J'
o
r
00
Z
o
;::
"
rr
I-
00
Ci
W
rr
W
(!l
"
cr
0:
"
::;
..
o
W
!;;:
<.l
rr:
;::
rr
w
<.l
W
0:
W
r
;:
00
00
W
0:
o
o
"
~
13
W
Il.
00
0:'
W
10
::;
::J
Z
o
z
"
I-
W
W
0:
l-
(/)
+
a:~z w
~~~
~~~ ~
I-wZ ....
~drn 0
~~g u:
~~~ ~
tEOOO W
01->-
wlli<30
Sffi'"
zgO':
COUNTY Dutchess
CITYfTOW VVapplnger
DISTRICT f::Sot$ .
NUMBER
REGISTER 1 U
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Richard George Schweitzer
MIDDLE CURRENT SURNAME
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
JoAnn Farmer
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST MIDDLE CURRENT SURNAME
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT. Joann Heck
C SURNAME AFTER MARRIAGE Schweitzer
(OPTIONAL - SEE REVERSE) 120-46-1539
D. SOCIAL SEf,JV NUMBER
12. RESIDENCE A. B. Dutchess
(STATE) "'- (COUNTY)
C. CHECK O~J;. . 0 CITY U TOWN 0 VILLAGE
~~~CIFY vvapplnger
'16 vanwert Place 12538
D. STREET ADDRESS ZI,i
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ 6'
13. A. AGE 42 3B. DATE OF BIRTH 07 /12 )t 6
MONTH DAY YEAR
14. EMPLOYMENT .
A. USUAL OCCUPATION Customer Service
Central Hudson
B. TYPE OF INDUSJRY O~ ~USINESS
15. PLACE OF BIRTH r'ougnKeepsle, New YorK
(CITY, STATE I COUNTRY IF NOT USA)
Il.
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 144-36-1429
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Ulster
(ST ATE)..L (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS L 1::So Koute ::SUU ZIP 1 Lo89
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '9 NO
3 A AGE 62 38 DATE OF BIRTH 02 / 06 / 947
MONTH DAY YEAR
4. EMPLOYMENT
A USUAL OCCUPATION Commercial Representative
B TYPE OF INDU~RY OR BUSINESS Central Hudson
5. PLACE OF BIRTH assaic, New Jersey
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME John Heck
'B. COUNTRY OFBIRTHU SA
17. MOTHER . .
A. MAIDEN NAME MarJone Albrecht
B. COUNTRY OF BIRTH USA
L
18. NUMBER OF THIS MARRIAGE
W
I-
;0
oo
6. FATHER
A. NAME Richard Schweitzer
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Eleanor Gimon
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 3
DEYH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI~ORCE CIVIL AN~ULMENT
DEbTH
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
~ ~
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (8@ DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) DONNULMENT g!f1DEATH
C. DATE LAST MARRIAGE ENDED? 03 / 04 / 2 8' C. DATE LAST MARRIAGE ENDED? 07 / 7 / 1
MONT'iI DAY YEAR MONT~ DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? tl 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 ISSUEO AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH~AY, YEA!!) (CITY/COUNTY. STAT~COUNTRY, IF "to] USA) SELF SPOUSE
1ST 03/04/2008 Goshen, New York 0 6 1ST 07/0, /199r PoughkeepSie, New york 0'
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affir ,depose and say, t at to owledge and belief that the information I provided is true a
as to my right to enter into the marr sta
o
o
w
en
z
w
o
::i
23. SUBSCRIBED AND SWORN TO FIRM BEFORE
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York S e bride and groom 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) Jo
TIME MONTH YEAR
SEAL SIGNATURE ~ :rE 03/11/2009
'-v-I MAI~~ItHF~81s ersFalls, NY 12590
05
10 2009
DATE
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
2009
03
12
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE ZIP
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
SIGNATURE~
DOH-9B (03/2006)