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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
E~Tn "Watt ~
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
100
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) D DEATH B. HOW DID lAST MARRIAGE END? (3)!l DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDE~?' ,-- m /17 /1aa:t
MONTH DAY YEAR MONTH DAY ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES D NO D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES D NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST.. D D 1sT02I1711~ CnnIrt'.n.nty.. IplNK ~ D
2ND D D 2ND D D
3RD D D 3RD D D
~ D D ~
I, being duly sWQrn, depose and say, that to the best of my knowledge and belief that the information I provided is true an
as to my right to enter into the marriage ate
21. SIGNATURE OF GROOM. . SIGNATURE OF BRIDE.
COUNTY Dutchess
CITYfTOWN Wacolnger
~~J:~ 1368
REGISTER 92
NUMBER
1. A. FULL NAME
CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)1J::ot Dot '7799
D. SDCIALSECURITYNUMBER -~--
2. RESIDENCE A. New York B. ~
(STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
AND 0... ......____.;
SPECIFY rUUWII~e
D. STREET ADDRESS 63 Channlnavllle Roed ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
3. A. AGE 29 3B. DATE OF BIRTH 08 /28 /1975
MONTH OAY YEAR
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4. EMPLOYMENT
A. USUAL OCCUPATION Vistar's Assistant
B. TYPE OF INDUSTRY OR BUSINESS Museum Of Modem Art
5. PLACE OF BIRTH Hemcsteed. NwI York
(CITY, STATElCOUNTRY IF NOT USA)
6. FATHER
A. NAME Bruce Nelson perry
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Beverly Carol stein
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
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9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
---,
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L 0 SUPPLEMENTAL FILE
.-J
11. A.
FROM THE BRIDE
FULL NAME H..dl!t TerepI ~delm8n
FIRST I
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~delman
(OPTIONAL. SEE REVERS~
D. SOCIAL SECURITY NUMBER 324-68-1655
12. RESIDENCE A.NelfAXrrr B. ~I
C. CHECK ONE D CITY Pi TOWN D VILLAGE
AND 0-. ......w.-i
SPECIFY ....~._~A
D. STREET ADDRES&63 Channll'\g.wllle ROAd ZIP 1259()
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
13. A. AGE~ 13.B. DATE OF BIRTH 'In tr 1~
-u'lNTH DAY tfUtEAR
14. EMPLOYMENT
A. USUAL OCCUPATIONR..gaNed Nllme
B. TYPE OF INDUSTRY OR BUSINESS \III:ItI1\g Nul'&A Of N Y
15. PLACE OF BIRTHHlMd8le.IIIINM
(CITY, STATEic!OUNTRY IF NOT USA)
16. FATHER
A. NAMERonsId Jerome ScheidelmRn
B. COUNTRY OF BIRTtlJ S A
17. MOTHER
A. MAIDEN NAME l<ballde Selma Bunnie
B. COUNTRY OF BIRn-Imq
18. NUMBER OF THIS MARRIAGE 2
DEATH
USE CURRENT NAME
DATE 0811812005
of the bride and groom named above by any person authorized by New York Domestic
ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
be used only for the pur ose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
DAT~1812OO5
Fills NY 12590
CITY/T WN STATE
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 D RELIGIOUS
9 D OTHER, SPECIFY
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK.
This license authorizes the marriage in New York Sta
Relations Law ~ 11 to perform marriage ceremonies within
D If checked, this license is t
~ 24. TOWN OR CITY CLERK
} NAME (PRINT) John . M
{SEAL SIGNATURE. .
"-y-I ~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
TITLE
DATE
A(
TIME
YEAR
10
17 2005
ZIP
1/cIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY .L);.;~5S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF 'TOWN OF D
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VILLAGE OF
SPECIFY
"B~AJ
NAME (PRINT)
SIGNATURE