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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Keith C Heinemann
FIRST MIDDLE
o 0 1~ 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
best of mt knowledge and belief that the infolTllation I provided ~ lhat I decI~.lhat n~~gal impedimen~ exists
22. SIGNATURE OF BRIDE~ ~ .J/i
U USE CURRENT NAME
23. SUBSCRIBED AND SWORN TOIAFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK~ DATE_
This license authorizes the marriage In Ne ork State of the bride and grool)'l named above by any person authorized by New York Domestic
Relations Law ~11 to perfOITll marriage ceremon within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CLTY.CLE~ 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT).JOnn ~. Masterson
{SEAL SIGN~:::~ OJ (J~~ . DA-re05I26f2OO6 TIME ~ MONTH
'-v-' ~~Rd, -wappinger Falls, NY 12590
STREET CITYIT WN ATE ZIP
~~~~RT~~~ 6~O~~N~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY .
SONS NAMED ABOVE ON THE E M DAY Y A 0 0 ReliGIOUS 1 ~...
DATE AND AT THE TIME AND AM
PLACE INDICATED. 9 0 OTHER, SPECIFY
COUNTY Dutchess
CITYfTOWN Wappinger
DISTRICT 1368
NUMBER
REGISTER 63
NUMBER
1. A. FULL NAME
CURRENT SURNAME
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N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)n~ DA559~
D. SOCIAL SECURITY NUMBER ~ "
2. RESIDENCE A. New Jersey B. Morris
C. CHECK ONE (STAO) CITY ~ TOWN 0 VllLAG~COUNTY)
~~CIFY Mount Olive
D. STREET ADDRESS 19 Tulane Road ZIP 07836
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
12 /03 /197B
MONTH DAY YEAR
3. A. AGE27
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Morris Knolls Hgh School
5. PLACE OF BIRTH Pouahlc8er8le.New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Laurence John Heinemann
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Carol Ann CUrrie
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
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DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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, STATEICOUNTl'IY, IF NOT USA) SELF SPOUSE
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1ST
2ND
3RD
4TH
I duly swear/affjlTll, dep'05e and S
as to my right to enter into th
21. SIGNATURE OF GROOM~
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-98 (07/2005)
I
STATE RLE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
--,
I
11. A.
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULLNAME ~At~I"e EP1m~ing
~
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. sttSN~~~~~~~nemllnn
D. SOCIAL SECURITY NUMBER 1 ~ 72-7RR1
12. RESIDENCEANefrApey 8.M-,)
C. CHECK ONE 0 CITY @ TOWN 0 VIlLAGE
~~CIFY Mount Olive
D. STREET ADDRESS19 TfjaM RMd
Z1p()7836
E. IS RESIDENCE WITHIN LIIIITS OF aTY OR INlXlRPORAlED VILLAGE? 0 YES..tl . NO
~ .DAY 1~
13. A. AGE25
38. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATIONNIII'IIP-
B. TYPE OF INDUSTRY OR BUSlNESSPrlvIltA Dnatofice
15. PLACE OF BlRTHMount Veman "W YOIt
(CIlY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMel'..harlf!R 1-1 n.Ji'1g
B. COUNTRY OF BIFrolJ S A
17. MOTHER
A. MAIDEN NAME Tina UAlVWcnhn
B. COUNTRY OF BllmU SA" .. .. ..
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
C. DAlE LAST MARRIAGE ENDED?
MONTH DAY YEAR
O. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNUULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYIOOUNTY. STA1E/COlRO/TRY,IF NOT USA) SELF SPOUSE
YEAR
A.
c.
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SIGNATURE~