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COUNTY Dutchess
CITYfTOWN Wappinqer
~~~:~ 1368 '
~~~I~~~R 59
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Andrew William Fischer
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Stephanie Lyn Gorman
MIDDLE CURRENT SURNAME
1 , A, FULL NAME
11, A. FULL NAME
FIRST
FIRST
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B, BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Fischer
(OPTIONAL - SEE REVERSE) 376 04 9755
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. MiCh,,' an B. Midland
(STAT (COUNTY)
C, CHECK ONE CITY 0 TOWN 0 VILLAGE
~~~CIFY Midland
D. STREET ADDRESS 1500 Lee Street ZIP 48642
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
08 /10 /1979
MONTH DAY YEAR
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 086 68 8133
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. Mic,an B. Midland
(STA (COUNTY)
C. CHECK ONE CITY 0 TOWN 0 VILLAGE
~~~CIFY Midland
STREET ADDRESS 1500 Lee Street
D.
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A, AGE 39 3B. DATE OF BIRTH
ZIP 48642
r:! YES 0 NO
13. A. AGE 27
3B. DATE OF BIRTH
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LL.
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4. EMPLOYMENT
A. USUAL OCCUPATION PrQject Coordinator
B. TYPE OF INDUSTRY OR BUSINESS Construction
5, PLACE OF BIRTH Inalewood. California
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Richard Varik Fischer
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Marlynn-Ann JOY Feickert
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 2
14. EMPLOYMENT
A: USUAL OCCUPATION Accountant
B. TYPE OF INDUSTRY OR BUSINESS Snow Machines Inc.
15. PLACE OF BIRTH Midland. MichiQan
(CITY, STATE I COUNTRY IF NOT USA)
16, FATHER
A. NAME Scott Anthony Gorman
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Mitzi Annette Hickerson
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
DEATH
o
9. ~~~~~~~R~r~~8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) dDIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 02/ 06 /
MONT~ DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? D'YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
02/06/1997 Midland, Michigan d
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
, '.- YEAR
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
(2) 0 DEATH
1997
YEAR
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YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~\ltt~
SIGNATURE~
DoH-98 (0312006)
Z
31. WITNESS TO CEREMONY
NAME(PRIN11: ~--: C:/Ir~
SIGNATURE~
/
/