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COUNrDlltchess
CITYlTowrWappinger
~~~:~CR1368
~~~I~~~~ 29
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Cort'lrDL~yndE'n G~~~NT SURNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Am~nrl~ R~r.hpl Frommhnlrl
FIRST MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL, SEE REVERSIil.
D. SOCIAL SECURITY NUMBER ()9B-70-4199
2. RESIDENCE ANY B. nlltr.hp~c;
(STATE) (COUNTY)
C. CHECK ONE 0 ciWD TOWN 0 VILLAGE
AND W .
SPECIFY ~pplngpr
D. STREET ADDRESS 1 0 Maloney Road. Apt. A5 ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YEll""D NO
3. A. AG181 3B. DATE OF BiRTH J2~ / Ci9y /1y~~6
4. EMPLOYMENT
A. USUAL OCCUPATION(\lIlr~p
B. TYPE OF INDUSTRY OR BUSINESsHealthcare
5. PLACE OF BIRnM;::!nhasspt I New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME~tpvpn IrvinO r,r~ff
B. COUNTRY OF BIRTHU S A
7. MOTHER
A. MAIDEN NAME Barbara Gail Geisler
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE' ' .. ......_.---CIVlt'ANNUl:MENT.
o 0
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~N~~~~~~~~~~-g~ff
D. SOCIAL SECURITY NUMBER ...J 26-60-6863
12. RESIDENCE NY Dlltr.hpss
(STATE) (COUNTY)
C. CHECK ONE 0 ClnYtJ TOWN 0 VILLAGE
AND _\^' .
SPECIFWvapplnger
D. STREETADDREsi10 Maloney Road. Apt. A5
z,~2603
o YE~D NO
1977
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE?
13. A. AG~O 3B. DATE OF BIRTH Of) AR
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATlorNurse
B. TYPE OF INDUSTRY OR BUSINEsd-lealthcare
15. PLACE OF BIRTtSharon. Connecticut
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMiRlldnlph Paul Frommhold
'B. COUNTRY OF BIRrW S A
17. MOTHER
A. MAIDEN NAMRachel Claire Meunier
B. COUNTRY OF BIRrW 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
(2) d;bEATH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
. '.- YEAR
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) (CITYICOUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
o
o
o
1ST
2ND
3RD
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFOR
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New 'York Slate 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
n . Masterson
by New York Domestic
w
(/')
Z ~
W { } NAME (PRINT)
~ SEAL SIGNATURE
'-.t-' M~~NK.ffl
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
2:23
AM 0
PM
TIME
MONTH
YEAR
DATE 1 % 1/2007
s, NY 12590
STATE ZIP
27. TYPE OF CEREMONY _ /
o 0 RELIGIOUS 1 !fIo"CIVIL
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCU~ . _ . _It
A. STATE NEW YORK B. COU~
C. LOCATION OF CEREMONY
(CHECK ONE AND CIFY)
,~
SIGNATURE~