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COUNTYnlltr.he~~
C1TYfTOWNW~ppingAr
~~~:~c;1368 . '.. .
REGISTE"2
NUMBER
~ I A II:. UI- NI:.W YUHK.
DEPARTMENT OF HEALTH
AFADAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mic~Jay FrieQmi~ SURNAME
FIRST
(THIS SPACE FOR STA TE USE ONL Y)
-.J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
CatheriijjLl~Aaria \I0QU~~URNAME
1 . A. FULL NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 111-60-9346
2. RESIDENCE A. NY B. 0' ,t,.kA88
(STATE) (~fI'J
C ~~6CK ONE 0 CITY.,t] TOWN 0 VILLAGE
SPECIFY VVappinger
D STREET ADDRESS 1 06 Cider Mill Loop ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YE~ NO
MQA / Q~ /1~7
C. s~S~t'~M~~~~EA~wc~~i~en Burg Friedman
D. SOCIAL SECURITY NUMBER 078-68-1867
12. RESIDENCE A NY(STATE) BD~ss
C CHECK ONE 0 CITY 0 TOWN~ VILLAGE
~~~CIFY'^'appingers Falls
D. STREET ADDRE~2 Spring StrAAt zIP1 ?~~O
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? IlJ YES 0 NO
nil ~'DAY 1P~7
"tiONTH . ~
13. A. AGE40
14. EMPLOYMENT
A. USUAL OCCUPATIONTeacher
B. TYPE OF INDUSTRY OR BUSINESS Red Heel<' Sch
15. PLACE OF BIRTH~8~~~T~rcE6~JJ~~ Nf6lT<D~% Y orl<
16. FATHER
3. A. AGF40
4. EMPLOYMENT
36. DATE OF BIRTH
36. DATE OF BIRTH
A USUAL OCCUPATION Eloctrician
6. TYPE OF INDUSTRY OR BUSINESS Electrical
5. PLACE OF BIRTH~~~~~~,.~~ York
6. FATHER
[)ist
. A ~~t:"'EHonald Bruce Friedman
B., q?~~~:I~~,BIRTH U S .A.
7.. MOTI;U=R ' ,.
':A. MAIDEN NAME D8ana Elgart
B. COUNTRY OF BIRTH U S .A.
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
,A. NAMEHugo Von Burg
B. COUNTRY OF BIRTft I S A
17. MOTHER
A. MAIDEN NAME Brenda Diehl
B. COUNTRY OF BIRTftj S A
18. NUMBER OF THIS MARRIAGE ?
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE " .-CIVIL ANNULMENT
DEATH
DEATH
o
(2) 0 DEATH
100
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? . ~ONTP3 / Q~ .( ~3
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/C()UNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSt.'\V6IVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, D.AY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST .' ....,- 0 0 0 >tI
2ND 0 0 0 0
3RD 0 0 0 0
40
23. SUBSCRIBED AblD ~W'lRN TO/AFFIRMED BEFO
SIGNATURE OF_TOWrilORCITY CLERK ~
This license authorizes the marriage in New York State of th bride and groom named above by any person authorized
Relations LaW~11..tD perform marriage ceremonies within New York S . THIS LICENSE VALID IN NEW YORK ST,Al,E ONLY.
. ."...... 0 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
A
by New York Domestic
~
{ SEAL}
~
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
DATE 01/04/2008 . .
10.: 17 AM
PM
O~
05
,:
SIGNATURE ~ ---t
MAILING A?DRESS I~
03
04 2008
2008
ZIP
C
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR 0
/
OZ
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUN~ltrc If,":%;
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY [1 (1-f1 (Al{.:'0f!5 hrlf.S
.
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICA]JD.
SIGNATURE ~
MAILING ADORES
I
STREET
30. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE"
DOH-98 (0312006)
iCe. fJ,e/6-s-r
e:( /1 r;j og'
r I
....
SIGNATURE~