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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Albert Michael Schwarz, JR.
MIDDLE CURRENT SURNAME
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, ilepose 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 ~e. mamage state. ~ ^ .l( ('\._ }.Ji.... (l j)"
21. SIGNATURE OF GROOM 22. SI ATURE OF BRIDE~l1.. ~
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ~:E C ENT AME . \S U E 09/05/2006
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York tate. 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 J6'fM C. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
COUNTY Dutchess
CITYfTOWN Wappinger
DISTRICT 1368 .
NUMBER
REGISTER 141
NUMBER
1 . A. FULL NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 11 0 70 6479
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r1 TOWN 0 VILLAGE
~~~CIFY East Fishkill
D. STREET ADDRESS 25 Wnght Boulevard ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES rf NO
3. A. AGE 21 3B. DATE OF BiRTH 07 / 10 / 198
MONTH DAY YEAR
STATE FILE NUMBEH
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jessica Leigh Costable
MIDDLE CURRENT SURNAME
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4. EMPLOYMENT
A. USUAL OCCUPATION Mechanic
B. TYPE OF INDUSTRY OR BU~lIl1E~S Heart Acura
5. PLACE OF BIRTH Town UT L;ortlandt, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
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A. NAME Albert Michael Schwarz
USA
B. COUNTRY OF BIRTH
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Schwarz
(OPTIONAL - SEE REVERSE) 056-74-0401
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) nr (COUNTY)
C. CHECK ONE Q CITY TOWN 0 VILLAGE
~~~CIFY East Fishkl
D. STREET ADDRESS 2b wnght Ijoulevard
12o;:S;:S
ZIP
MONTH
7. MOTHER
Dorothea Jean COX
A. MAIDEN NAME
USA
B. COUNTRY OF BIRTH 1
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVO~E CIVIL ANN~ENT
DEAcr
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VILlAGE?
13. A. AGE 23 3B. DATE OF BIRTH 06
14. EMPLOYMENT
A. USUAL OCCUPATION Paramedic
B. TYPE OF INDUSUlY OR BUpll'iE$S I rans<.;are
15. PLACE OF BIRTH L;armel, New YorK
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Leonard Carmel Costable
. B. COUNTRY OF BIRTH U ~ A
17. MOTHER J M' N'k't I
A. MAIDEN NAME oan ane I I opou os
U~A
B. COUNlTRY OF BIRTH I
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVerCE CIVIL AN~LMENT
DEff
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATI1
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CrrYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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{ SEAL }
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STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE
appinger Falls, NY 12590
ZIP
03:2~~
09
2006
11
SIGNATURE ~
MAIL~AfVr~m
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
TIME
MONTH
YEAR
MONTH
YEAR
06
CrrYlTOWN STATE
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. Y YEAR O;s:.RELIGIOUS
W J;IJ5(AM 10 :t <jJ' (76 9 0 OTHER, SPECIFY
~ 29'OFFICIANT~ ~~~ "'
(,) NAME (PRINT) ~ TITLE
u: SIGNATURE~ ~ DATE /P /.:28'~~
i= MAILING ADDRESS . n '
a: 2.3 .91J.,,/D,1 :L?2,v~ ~~ w.K-~Q P;{f, ;U'f J.:z~3
W STREET CITYfTOWN STATE
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NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY IJiJJ711ft!i$ Ii
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 18[ TOWN OF 0 VILLAGE OF
SPECIFYFi~~JL'- - .n;.H~/~(....
;B~"::;7r elfd~jr
NAME (PRINT)
SIGNATURE~