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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST ChristoPMEEMichael ~l;M;~~QifME
COUNTY Dutchess
CITYfTOWN \^'appinger
~~~:~c~ 1368
~~~~~~R 80
1. A. FUll NAME
ll.
N
B. BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 122 -60-4 7 50
2. RESIDENCE A. NV B. n, ,tf'h8SS
-rSTATE) '"'(coOO'1)
C. CHECK ONE 0 CITY $J TOWN 0 VILLAGE
AND \^' .
SPECIFY . applnger
D. STREET ADDRESS 15 norett nri\/p ZIP 1 ?!190
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..t) NO
M~ / g,? / ~:1:17
3. A. AGE 31
4. EMPLOYMENT
A. USUAL OCCUPATION Truck Driver
B. TYPE OF INDUSTRY OR BUSINESS Tp 'ekina
5. PLACE OF BIRTH New Ror-helle NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
3B. DATE OF BIRTH
A. NAME Thomas K8nneth Schreiber
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Margaret Ita1i(;lno
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
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
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
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and sayyJh
as to my right to enter intD the malTla:
I.l
21. SIGNATURE OF GROOM~ .
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Drk 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
DATE 07/02/2008
II NY 12590
STATE ZIP
27. TYPE OF CEREMONY _./
o 0 RELIGIOUS 1 ~ CIVIL
9 0 OTHER, SPECIFY
w
en
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{ SEAL }
~
NAME (PRINT)
WN
NAME (PRINT)
SIGNATURE~
DOH-98 (D3/2006)
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL V)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Eliza~~tP Anne L~b~~~NT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. s~S~~~J",~E~~t~~O~~~)chreiber
D. SOCIAL SECURITY NUMBER !1~0-94-3079
12. RESIDENCE ANY B [Illtr.hes!=:
(STATE) (COUNTY)
C CHECK ONE 0 CITY..tJ TOWN 0 VILLAGE
AND \AI .
SPECIFY ;::)rrlnOAr
D. STREET ADDREss15 Dorett Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..o NO
13. A, AGE2"'7 3B. DATE OF BIRTH O? da )('Q81
-I- MtiNTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Mprlir.;::) I M;::)n;::)gpr
B. TYPE OF INDUSTRY OR BUSINESS Medical Management
15. PLACE OF BIRTHI (~~, XA~~~O~NT~YNOT USA)
16. FATHER
A. NAMEHyl(;l!=: Arr.hip I pwi!=:
. B. COUNTRY OF BIRTrU S A
17. MOTHER
A. MAIDEN NAME Susan Marie Anderson
B. COUNTRY OF BIRTrU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 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
1ST
2ND
3RD
o
o
o
o
o
o
DATE
07/02/2008
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
MONTH
DAY
YEAR
DAY
YEAR
AM
06:49PM 07
03
2008
08
31 2008
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~U\'j~ ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~N OF 0 VILLAGE OF
SPECIFY W f.tt1JfJP ~
NAME (PRINT)
SIGNATURE~