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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Benjamin FdlIwArd MArkel
I ST MIDDLE
COUNTDI dche~!;
CITYfTowrWRppinger
~~~~kCR1368
~5~~J~~ 26
1. A. FUU NAME
CURRENT SURNAME
0-
N
B BIRTH NAME, IF DIFFERENT
C. SU RNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEj,
D SOCIAL SECURITY NUMBER '.49-77-4n13
2. RESIDENCE A.NJ B Fssex
(STATE) (COUNTY)
C. CHECK ONE 0 CITY~ TOWN 0 VILLAGE
AND
SPECIFY Mflplewond
D. STREET ADDREss49 Yale 51. ZIP 07040
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"D NO
3. A. AGf2~ 38. DATE OF BIRTH nl:;TH /n7 /1QR1
-W~ DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION nirer.t Marketer
8. TYPE OF INDUSTRY OR BUSINESS Marketing
5. PLACE OF BIRTHI ivinoston" New Jersey
(CITY, mATE/COuNTRY IF NOT USA)
6. FATHER
A. NAME Rotten MArkel
8. COUNTRY OF BIRTH U 5 A
7. MOTHER
A. MAIDEN NAME Deena fu'A7er
B. COUNTRY OF BIRTH l J S A
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
c." DATE LAST MARRIAGE ENDED? / /
12) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
~
11. A.
FROM THE BRIDE
FULL NAMELindsev Tayer Herberger
FIRST MIDDLE
CURRENT SURNAME
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Markel
(OPTIONAL - SEE REVERSE095-10-9159
D. SoCIAL SECURITY NUMBER
12. RESIDENCE ,New York BDutchess
(STATE).L (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFJ,.a Grange
D. STREET ADDRES~ Fox Run
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGF23 13.8. DATE OF BIRTH 01 YI
12590
ZIP .,
o YES 0 NO
1982
DAY YEAR
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATIONSocial Worker
B. TYPE OF INDUSTRY OR BUSINEssfam11y ~eMces
15. PLACE OF BIRT~oughkeepsie, New York
(CITY, ST ATElCOUNTRY IF NOT USA)
16. FATHER
A. NAME Robert Albert Herberger, Jr.
B. COUNTRY OF BIRTJJ S A
17. MOTHER
A MAIDEN NAME Denise Frances Pengitore
B. COUNTRY OF BIRn./.J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIOORCE CIVIL A~ULMENT
D'1jTH
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
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to the best of my
as to my right to enter into the marriage state.
--'1
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
wledge and belief that the information I provided is tr
o 0
o 0
o 0
o 0
pediment exists
21. SIGNATURE OF GROOM"
23.
w
en
z
w
()
:J
,-'-..
{ SEAL }
'-v-'
22. SIGNATURE OF BRIDE ~
~
by New York Domestic
TIME MONTH
YEAR
MONTH YEAR
ZIP
06:35 ~~ 09
2005
11 21 2005
29
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY DVT (H1:JJ
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF )( TOWN OF 0 VILLAGE OF
,.
SPECIFY j'Oi-lG/-IKlf"cI'S/t:
o 5- RELIGIOUS 1 0 CIVIL
b~ 90 OTHER, SPECIFY
TITLE (?~). - C/hI 7 ur
DATE ~/o5'
N -- b70 t(lJ
STATE
/'