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COUNTY Dutchess
CITYfTOWN WappinQer
~~~:~c;1368
~5~1~~~R 163
~ I "" I I;;. ur nil;;. VV . unn.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Stephen Erik HiRJilauf
MIDDLE URRENT SURNAME
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Christine Thea Daverese
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
c.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Hippauf
(OPTIONAL' SEE REVERSE134_62_1428
D. SOCIAL SECURITY NUMBER
12 RESIDENCE ANY BDutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~~C'FYPoughkeepsie
o STREETADDREss17 Old Farms Road
ZIP 12603
D YEStJ NO
;1'977
YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)122 60 8789
o SOCIAL SECURITY NUMBER --
2. RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITYoCI TOWN D VILLAGE
~~~CIFY Poughkeepsie
o STREET ADDRESS 17 Old Farms Road ZIP 12603
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES~ NO
11 /26 /1971
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE31 3B, DATE OF BIRTH 08 "el2
MONTH DAY
3. A AGE36
3B. DATE OF BIRTH
4, EMPLOYMENT
A. USUAL OCCUPATION Maintenance
B, TYPE OF INDUSTRY OR BUSINESS Car Wash
5. PLACE OF BIRTH Poughkeepsie , Nv
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Richard Berthold Hippauf
B. COUNTRY OF BIRTH USA
7, MOTHER
A. MAIDEN NAME Melba Christine Fanos
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATIONAdministrative Assistant
B. TYPE OF INDUSTRY OR BUSINESS Car Wash
15. PLACE OF BIRTHBronx. Ny
(CITY, STATE / COUNTRY IF NOT USA)
16, FATHER
A. NAME Victor Anthony Daverese
. B, COUNTRY OF BIRT~ S A
17, MOTHER
A, MAIDEN NAME Dorothea Helen Cordts
B. COUNTRY OF BIRT~ S A
18, NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B, HOW DID LAST MARRIAGE END? (3) D DIVORCE
C, DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
(3) D ANNULMENT (2) D DEATH
/ /
, - YEAR
YEAR
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C, DATE LAST MARRIAGE ENDED?
MONTH DAY
D, ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
MONTH DAY
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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and s
as to my right to enter into the ma
21, SIGNATURE OF GROOM~ .
D
D
D
D D
D D
D D
D D
Ie al impediment exists
22. SIGNATURE OF BRIDE
w
en
z
w
o
::i
US
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New rk 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.
D 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) Joh C. Masterson
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~. DATE 10/22/2008
MAILING ADORES 09 41 AM
'-v-' 20 Middle ush Rd, WappinQers Falls. NY 12590 : 10 23 2008 12 21 2008
STREET CITYITOWN STATE ZIP PM
~~~R~~RT~~~ 'o~O~~~N~Zi~ 26, SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR oXX RELIGIOUS
DATE AND AT THE TIME AND :JANI
PLACE INDICATED. 2: 00 PM 11-8-2008 9 D OTHER, SPECIFY
DATE
10/22/2008
YEAR
2B. PLACE WHERE MARRIAGE OCCURRED
1 D CIVIL
A. STATE NEW YORK B. COUN-rPutchess
w
...
~ ~~t~n~~~~ D~aniel B. Ward
~ SIGNATURE~ ~-<-~~
... MAILING ADD~
~ St. John's Lutheran Church 55 Wilbur
W STREET CITYfTOWN
o 30, WITNESS TO CEREMONY
NAME (PRINT)Richard
,
C, LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
TITLEPastor
!XI CITY OF D TOWN OF D VILLAGE OF
sPEclFloughkeepsie
DATE11-08-2008
Boulevard, Pok,
STATE
NY
126 3
ZIP
31, WITNESS TO CEREMONY
Victoria
NAME (PRINT)
SIGNATURE~