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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Peter William Kiesbye
MIDDLE CURRENT SURNAME
o 1ST
o 2ND
o 3RD
o 4TH
d belief that the information I provided is tru
USEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Y Ii 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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) John C. Masterson
TIME MONTH YEAR
SEAL SIGNATURE~' DATE 01/05/2009
MAILING ADDRE~S AM
"-.t-I 20 Middle ush Rd, WappinQers Falls, NY 12590 03:59PM 01
STREET CITY/TOWN STATE ZIP
~~~R~:RT~tJ 'o~O~~~N~;~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY /
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 00 RELIGIOUS 1 lJ!l'CIVIL
DATE AND AT THE TIME AND AM 'i
PLACE INDICATED. 0 I 0 0200'{ 9 0 OTHER, SPECIFY
COUNTY Dutchess
CITYfTOWN Wappinger
~~J~~:1368
~5~I~J~R 1
1 . A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSEb60_7 4-0 514
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 1668 Route 9; Umt 12J ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 1J NO
3. A. AGE 34 3B. DATE OF BIRTH 03 / 22 /1974
MONTH DAY YEAR
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C
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4. EMPLOYMENT
A USUAL OCCUPATION HV AC Technician
B. TYPE OF INDUSTRY OR BUSINESS Mechanical Service
5. PLACE OF BIRTH Mount Kisco, Ny
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Daniel B. Kiesbve
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME InQrid I. Szirmay
B. COUNTRY OF BIRTH Germany
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
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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Laura Ann Sheats
~
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Kiesbye
(OPTIONAL. SEE REVERSE)154-78-6256
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(STATE).L (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS' tme Koute 8; unit 1 LJ ZIP "I Lo~U
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE29 3B. DATE OF BIRTH 07 ,28 )'979
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Branch Administrator
B. TYPE OF INDUSTRY OR BI,JSINES~ Landscaping
15. PLACE OF BIRTH Plainfield, NJ
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Kevin Mitchell Sheats
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Lynn Ann Zukoski
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE '
19. 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 (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (,
MONTH DAY 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/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
22. SIGNATURE OF BRIDE
MONTH
YEAR
06
2009
03
06 2009
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY Dult.ltesS'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
TITLE M/i#.l A6f af:f.1 c.EIt-.
DATE-d-EJol
Ia.-SCio
STATE
NAME (PRINT)
SIGNATURE~
DOH-98 (03/2006)
SPECIFY l.IJ A:fJP I rJG..tI<-.
NAME (PRINT)
SIGNATURE~