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COUNTY Dutchess
CITYfTOWN WappinQer
~~~:~c~ 1368
~~~I;J~R 62
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
JOD'~Diictor Zie~J~~NTsuRNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Patri~li~l~ane Mcq~~~T SURNAME
1. A. FUll NAME
11. A. FUll NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D SOCIAL SECURITY NUMBER 116-74-9775
2 RESIDENCE A NY B. Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY ..0 TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D STREET ADDRESS 19 Alpine Dr.; Apt G ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"!'J NO
3 A. AGE ?R 3B. DATE OF BIRTH 01 / 15 /1980
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE Ziegler
(OPTIONAL. SEE REVERSEIO 3 76 006
D. SOCIAL SECURITY NUMBER 9 - -5
12 RESIDENCE ANY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY '!"'J TOWN 0 VILLAGE
~~~CIFY WappinQer
D STREET ADDRESS 19 Alpine Dr.; Apt G
ZIP 12590
DYES '6 NO
/1'"984
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13, A, AGE 24 3B. DATE OF BIRTH 03 /'19
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Carpenter
B. TYPE OF INDUSTRY OR BUSINESS Local 157
5. PLACE OF BIRTH Poughkeeosie, NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME John Jacob Ziegler
B. COUNTRY OF BIRTH USA
7, MOTHER
A. MAIDEN NAME Elizabeth Carmel Caroenter
B. COUNTRY OF BIRTH USA
8. 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 OCCUPATION Personal Trainer
B, TYPE OF INDUSTRY OR BUSINESS Personal Trainer
15. PLACE OF BIRTH New Rochelle , NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Charles Kevin McGoey
. B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Jane Marv Hulsebosch
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
DEATH
o
DEATH
o
B, HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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 OIVORCED 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 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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose an
as to my right to enter into the
21. SIGNATURE OF GROOM~
o
o
o
o
o
o
o 0
o 0
o 0
o 0
pediment exists
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USE
23. SUBSCRIBED AND SWORN TO/AFF MED BEFORE ME
SIGNATURE OF TOWN OR CITY Cl K ~
This license authorizes the marriage in New Y Ie of the bride and groom named above by any person authorized
Relations Law 911 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 C. Ma terson
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE
MAILING ADDRES AM
"--v-I 20 Middle 05:52PM 06
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE
by New York Domestic
MONTH
YEAR
05
2008
08
03 2008
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 f"/f...OF, I2!DVILLAGE OF
SPECIFY~
?-ll
ZIP
WITNESS TO CERE~NY .
, .
NAME (PRINT) 0\1'"
SIGNATURE~