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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
las~Ddosiah Ba'el~~~ SURNAME
COUNTY n'ltr.hp.ss
CITYfrOWN W::lppingp.r
~~~:~CRT 1 ~RR
~~~I;;~R 114
1 . A. FULL NAME
FIRST
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N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 :i4-7?-11 ~R
2. RESIDENCE A N'lsTATE) B. q!!t~:P)E"S"
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 1025 Dutcher Drive ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
3. A. AGE 26 3B. DATE DF BIRTH MO~ / ~~ / ~E~R82
4, EMPLOYMENT
A. USUAL OCCUPATION GO\ll'lrl1ml'lnt Cnntr::lr.tnr
B. TYPE OF INDUSTRY OR BUSINESS Govp.rnmp.nt
5. PLACE OF BIRTH North Hp.mn~tp.::ld Ny
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Gre>gory Ste>"I'ln R::llltist::l
B. COUNTRY OF BIRTH LJ S A
7. MOTHER
A. MAIDEN NAME I ::lllr::l Rosp. Acarnn
B. COUNTRY DF BIRTH l J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
K::ltrin::l .Jamp.s Rauff
MIDDLE CURRENT SURNAME
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENTR::lllff-I\JIi Isser
C. SURNAME AFTER MARRIAGE R::lllti~t::l
(OPTIONAL. SEE REVERSE)200 64 6375
o SOCIAL SECURITY NUMBER ___ - _ -
12. RESIDENCE A NY BDutchp.ss
(STATE) (COUNTY)
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 1025 Dutcher Drive
14. EMPLOYMENT
A. USUAL OCCUPATION Compensation Analyst
B. TYPE OF INDUSTRY OR BUSINESS Finance
15. PLACE OF BIRTH Centre Pennsylvania
(CITY, STATE / COUNTRY IF NOT USA)
16, FATHER
A NAME Rodnp.y Earl Musser
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Yvette Louise Rauff
B, COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
ZIP 12524
DYES '6 NO
A~83
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE?
13, A. AGE?!; 3B. DATE OF BIRTH 04 A?
MONTH DAY
DEATH
o
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
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
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1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, depose and say. that to the best of my knowledge and belief that the information I provided is true and that I declare t
as to my right to enter into the marnage state,
;.--
o 0
o 0
o 0
o 0
t no legal impediment exists
23. SUBSCRIBED AND S RN TO/AFFIRMED BEFO E
SIGNATURE OF TO.WN OR CITY CLERK ~
This license authorizes the marriage in New York State of the 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
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(,)
::;
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{ SEAL }
'-v-I
NAME (PRINT)
22. SIGNATURE OF BRIDE~
DATE
08/22/2008
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
DATE 08/22/2008
In ers Falls NY 12590
ITV WN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ,/
TIME MO, DAY YEAR 0 0 RELIGIOUS 1 It' CIVIL
0'" ~ " I;.ot" 9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT ) C H /II 1-1 -:tlS; 1= '-PJ
NAME (PRINT) - . _----=-
SIGNATURE~ d.. I( '/"-
MAILING ADDRESS 7~----
2/ GVRlO ST. N'I,Al..1(
STREET CITYfrOWN
3D. WITNESS TO CEREMONY
AM
02:46PM 08
23
2008
10
21 2008
28. PLACE WHERE MARRIAGE OCCURRED
A, STATE NEWYORK B,COUNTY (b'-l(l/JJV>>
J\i ~'t~ R
DATE"" S.e Pr: l..~jY
M3t...1 'r~1(1(.
STATE
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF D-'t1tLAGE OF
SPECIFY N'~ 4- (.1<'
TITLE
N't
NAME (PRINT)
SIGNATURE~
DOH-9B (03/2006)
NAME (PRINT)
SIGNATURE~