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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~ 1368 '
~~~I:~~R 22
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Charles E. Palmateer. Jr.
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jane Elizabeth Weidner
FIRST MIDDLE CURRENT SURNAME
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT Grant
C. SURNAME AFTER MARRIAGE Weidner-Palmateer
(OPTIONAL' SEE REVERSE) 058-30-2401
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY cY'TOWN 0 VILLAGE
~~CIFY Wappinger
D. STREET ADDRESS 21 Shale Drive
.-J
1 , A. FUll NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 134-28-0104
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY [l( TOWN 0 VILLAGE
AND W '
SPECIFY aoomger
D. STREET ADDRESS 21 Shale Drive
ZIP 12590
YES [jtNO
/19~7
YEAR
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INODRPDRATED VILlAGE? 0 YES d' NO
12 / 11 / 193
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INODRPORATED VILlAGE? 0
13. A. AGE 70 3B. DATE OF BIRTH 01 /01
MONTH DAY
'3. A. AGE 71
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION
14. EMPLOYMENT
A. USUAL OCCUPATION Secretary
B. TYPE OF INDUSTRY OR BUSINESS Astor Home For Children
15. PLACE OF BIRTH Bronx, New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Alexander David Grant
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Evelyn Louise Branch
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 2
Retired
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Charles E. Palmateer. Sr.
B, COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Hilda Frances Sutton
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DEATH DIVORCE CIVIL ANNULMENT
1 1 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) Ol{EATH B. HOW DID LAST MARRIAGE END? (3) O,;'IVORCE (3) 0 ANNULMENT J.2l.P DEATH
C. DATE LAST MARRIAGE ENDED? 02/ 15 / 2006 . C. DATE LAST MARRIAGE ENDED? 01 / 15 / 1979
MONTH ~Y YEAR MONTH J DAY' '.- YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 fio D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
"
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 01/15/1979 Poughkeepsie, New York 0 ct
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the mam ge state, /7 _ _ $-: , '--"
21. SIGNATURE OF GROOM~ '.c 22. SIGNATURE OF BRIDE~ ~ ' ~~
USE CU i7 USE CURRENT NAME
23, SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME 03/28/2007
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New Yo State of the bride and groom named above by any person authorized by New York Domestic
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,
r-I'-.. 24, TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) John C. Masterson
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ ,71. DATE 03/28/200
'-v-' MAIL~B~cfm ush Rd, Wappinger Falls, NY 12590 07:1~~ 03 29 2007 05 27 2007
STREET CITYrrOWN STATE ZIP
~~~R~~Ri~~J lo~OW.~N~Zi~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME M. DAY YEAR 0 g RELIGIOUS
DATE AND AT THE TIME AND LJ AM 4 '" a ...,
W PLACE INDICATED. I PM '^- 0 0 I 9 0 OTHER, SPECIFY
5 ~~t~n~~~~. "-? _~'1rlfhof+ "'" Rwvo..ncl
u:: SIGNATURE~ ~ ~~ DATE '1/2.. ~ /0 I
~ f,'D~GWI~FishlJ II .. .. V'. N't ' 1,25 z'f
w STREET CITYfTOWN STtTE ZIP
o
g, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
YEAR
26. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY ~tc..h ~S s
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF g VILLAGE OF
SPECIFY F", s h ~)
30. WITNESS TO CEREMONY
NAME (PRINT) GA it Lf rZ. Plitt M '17 E"e'" Q
SIGNATURE~ ~1l1J~
DOH-98 (0312006)