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COUNTY Dutchess
CITYfTOWN Wappinger
~~J~~c; 1368 .
~~~'~;~R 186
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Victor David Arnold
MIDDLE CURRENT SURNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Elizabeth Ann Kalman
MIDDLE CURRENT SURNAME
.-J
1 . A. FULL NAME
1 1. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Kalman
(OPTIONAL - SEE REVERSE) 043 68-6087
D. SOCIAL SECURITY NUMBER -
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN rY VILLAGE
~~~CIFY WappinQers Falls
D. STREET ADDRESS 5310 Pincess Circle ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A. AGE 44 3B. DATE OF BIRTH 08 / 09 /1962
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 120-46-1007
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN &' VILLAGE
~~~CIFY Wappingers Falls
D STREET ADDRESS 5310 Princess Circle
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE fi? 38. DATE OF BIRTH 11 /
MONTH
ZIP 12590
D'" YES 0 NO
1 0 / 195
DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Plumber
B. TYPE OF INDUSTRY OR BUSINESS Pyramid Builders
5. PLACE OF BIRTH Pontiac, Michigan
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Charles Hugh Arnold
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Virginia Ann Rauch
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 3
14. EMPLOYMENT
A. USUAL OCCUPATION Accountant
B. TYPE OF INDUSTRY OR BUSINESS Jet Blue Airways
15. PLACE OF BIRTH Stamford, Connecticut
(CITY, STATE / COUNTRY IF NOT USA)
16, FATHER
A. NAME Bruce Allen Kalman
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Karen Warnke
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 3
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
2 0
DEATH
o
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
2 0
B. HOW DID LAST MARRIAGE END? (3) d"'t,VORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? oV 09 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? O"l"ES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 08/22/1988 Poughkeepsie. New York 0 if
2ND 01/09/2004 Poughkeepsie, New York 0.... 0
~ 0 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) c:ro,VORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 11 / 25 / 2003
MONTH DAY, '. - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? C:fo?ES 0 NO
~
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
04/15/1993 Stamford, Connecticut 0 d
11/25/2003 Danbury, Connecticut 0.... 0
o 0
o 0
pediment exists
(2) 0 DEATH
2004 '
YEAR
w
(J)
Z
W
o
::i
SECU
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
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.
,-I'-. 24. TOWN OR CITY CLERK 25. A. SOLEMNlZATI0N PERIOD BEGINS
{ } NAME(PRIND John
TIME MONTH YEAR MONTH
SEAL SIGNATURE ~
'-..t-I MAIL~B 'le.W~afebu 09:04\M 12
STREET PM
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
27
24 2007
2006
02
l~VIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~ t.J~ c;.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF gTOWN OF 0 VILLAGE OF
SPECIFY lj.)o t(" 'i e,r-
~
NAME (PRINT)
SIGNATURE~