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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Peter Matthew Waaner
FIRST MIDDLE
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly SWDrn, depDse and say, that to the best of my knowledge and belief that the Information I provided IS true and that I declOWl that no legal Impediment eXists
as to my nght to enter Into the mar~~ate. p - . ft I . ....
21 SIGNATURE OF GROOM ~ ~~ 22. SIGNATURE OF BRIDE ~ CA. tJ A Wll.l.LTu~
U . - 'l;;I7 USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
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.
~ 24 TOWN OR CJITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) ohn M
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ . .... DATJ.l9/07/2005
'-v-I ~IYflli'dme slfF<<rWappinger Falls NY 12590 9 08 2005 1 06 2005
STRE T CITYITOWN STATE ZIP
~~~R~~~Ri~~~ IO~O~~~N~zEE~ 26 SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 [l?" CIVIL
DATE AND AT THE TIME AND L' 0
PLACE INDICATED l7. 0 . ij /0 Q t oS 9 0 OTHER, SPECIFY
~~~t~~~~~T M\C.HA.t:l. R KENZ.O TITLEt0.;NiS1€~
SIGNATURE ~ lIIu~k(!j I? ffCf'Y?1J DATE 10.01- 05
MAILING ADDRESS ---zT
\<tlrv'lll.i.. S'T '?ol.lG.Hi<'tH'S1 t. N 1 12 /:'0 i
STREET CITyrrOWN STATE ZIP
30. WITNESS TO CEREMONY 31. WITNESS TO CEREMONY
COUNTY Dutchess
CITyrrOWN Wappinger
DISTRICT 1368
NUMBER
REGISTER 1 08
NUMBER
1 A. FUll NAME
CURRENT SURNAME
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B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE064-74-9979
D SDCIAl SECURITY NUMBER
2 RESIDENCE A. New York B Dutchess
(SWE) (COUN1Y)
C CHECK ONE LJ CITY 0 TOWN 0 VILLAGE
~~~CIFY pou~hkeepsie
D. STREET ADDRESS 47 Union Street, Apt. 2 ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? "6 YES 0 NO
02 /22 /19R1
MONTH DAY YEAR
3. A. AGE24
38. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Customer Service Rep.
8. TYPE OF INDUSTRY OR BUSINESS Regional Help Wanted .com
5. PLACE OF BIRTHCold Spring, New York
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME John Alan Wagner
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Pamela Louise Mc Inlyre
8. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVBRCE CIVIL AnNULMENT
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
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
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STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
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FROM THE BRIDE
11 A FULL NAME Frir.a Marie V\lilli~ms
FIRST MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Williams
c. SURNAME AFTER MARRIAGE Wagner
(OPTIONAL. SEE REVER~
D. SOCIAL SECURITY NUMBER 074-68- 363 2
12. RESIDENCE ANp.JTXE~rk 8. D~~~1S
C. CHECK ONE -tJ CITY 0 TOWN 0 VILLAGE
AND n hk .
SPECIFY....o....g eepsle
D. STREET ADDRESS 147 Union street I Apt 2 ZIP1 ~6n 1
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? o(J YES 0 NO
13. A. AGI=24, 13.8. DATE OF BIRTH 01;, ../,. <t ../,...
It'ItJNTH I:MI DAY IlKi 'EAR
14. EMPLOYMENT
A. USUAL OCCUPATIONKeyboard Spp.r.iRli~t
B. TYPE OF INDUSTRY OR BUSINEssNew York Siatp.
15. PLACE OF BIRT~ounhkeeDsieL New York
(CI'rt,'STATE/COU"NTRY I.. NOT USA)
16. FATHER
A. NAM5tephen Alan WiIliRm~
8. COUNTRY OF BIRTU S A
17. MOTHER
A. MAIDEN NAMERp.ginR Ann Ren70
8. COUNTRY OF BIRTlJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
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
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NAME (PRINT)
SIGNATURE ~
DOH.98 (11/98)
DATE 09107 {~nn~
by New York Domestic
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY l'V1'rnf\ ('J
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF [Sj VILLAGE OF
SPECIFY
(0\.0
St'R\\\.lG
NAME (PRINT)
SIGNATURE ~