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~~~
1 . A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Chrii~g~er ~~icha~~huRNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~c~ 1368 .
~5~1:~~R 130
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
P;:!mel;:! Ann Kiene
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 0 ~ 1 r ~ 021 0 .
D. SOCIAL SECURITY NUMBER _9 _ -;19-__ _ _
2. RESIDENCE A. NY B. Dlltr.hA~~
(iTATE) (CC5uNTY)
C. CHECK ONE 0 CITY W!I TOWN 0 VILLAGE
~~~CIFY F;:!~t Fi~hkill
D. STREET ADDRESS 10 Louise Lane ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES!!!'l NO
3. A. AGE 31 3B. DATE OF BiRTH M~ / DQ~ / vWS-
4. EMPLOYMENT
A. USUAL OCCUPATION RAt:::lil
B. TYPE OF INDUSTRY OR BUSINESS Lowe's
5. PLACE OF BIRTH..Cold Sprina, New York
(CITY, STATE I COUN'!fiV IF NOT USA)
6. FATHER
A. NAME r,;:!ry r,enrge Rne
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Jane Elizabeth Krieger
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 2
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Rne
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 128-70-8910
12. RESIDENCE A. NY B. nlltche~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY Ilil' TOWN 0 VILLAGE
~~~CIFY East Fishkill
D. STREET ADDRESS 10 Louise Lane
ZIP 12533
DYES!'l NO
/1'97R
VEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE?
13. A. AGE 29 3B. DATE OF BIRTH 01 ~9
MONTH DA V
14. EMPLOYMENT
A. USUAL OCCUPATION Ret;:!il
B. TYPE OF INDUSTRY OR BUSINESS ~. C. Penney
15. PLACE OF BIRTH Brooklyn. New York
(CITY, STATE I COUNTRV IF NOT USA)
16. FATHER
A. NAME Robert Martin Kiene
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Patricia Virginia Hammond
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
'DIVORCE CIVIL ANNULMENT
o 0
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE" ., ...... _....--..CIVlL-ANNtJI:MENTn
1 0
B. HOW DID LAST MARRIAGE END? (3) ~DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 02/ 27 / 2006
MONTH DAY VEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? [1<.ES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNmV, IF NOT USA) SELF SPOUSE
02/27/2006 Poughkeeosie. N Y
DEATH
o
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- VEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAV
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) (CITYICOUNTY, STATE/COUNTRV, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, aep'ose and say, that to
as to my right to enter into the ma e S
21. SIGNATURE OF GROOM ~
rf
o 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
owledge and belief that the information I provided is true and that I de"e ~t no legal impediment exists
22. SIG TURE OF BRIDE~ ~~. ~~ ~
USE CURRENT NAME
w
U)
Z
W
o
::i
USE CUR NT M
23. ~~~;~=~DO~~O~';::OJ'~ d"~A~:::f~E~ BEFORE ME DATE 1 % 1/2007
This license authorizes the marriage in New York State of authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York ate. 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
C. Mas er
r-I'-.
{ } NAME (PRINT)
SEAL SIGNATURE ~
~ MAI~ AAra~
smEET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICAT~D.
YEAR
MONTH
YEAR
TIME
MONTH
AM
12:31PM
2007
11
30 2007
10
02
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY()Jr~e..s~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 21 TOWN OF 0 VILLAGE OF
SPECIFY 'W o.~~ \ ('\'j~\
1 )U CIVIL
.#;
29. OFFICIANiT
NAME (PRI~:'.
NAME (PRINT)
SIGNATURE~