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. 1 A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Shaun Scott Seipp
FIRST MIDDLE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITYfTOWN Wappinaer
~~~~~CRT 1368
~G~I~J~R 89
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11 A. FULL NAME Christine Barbara Cohn
FIRST MIDDLE
CURRENT SURNAME
CURRENT SURNAME
a.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Seipp
(OPTIONAL - SEE REVERSE) 56-72 0918
D. SDCIAL SECURITY NUMBER 0 -
12. RESIDENCE ANew York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 1 0 I White Gate Drive
ZIP 12590
o YES tJ NO
19'14
YEAR
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEn78-70-9393
D. SOCIAL SECURITY NUMBER U
2. RESIDENCE A. New York B Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinaer
D. STREET ADDRESS 10 I White Gate Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIUAGE? 0 YES ~ NO
n? /14 /1Q1R
MONTH DAY YEAR
3 A AGE?7
3B. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE:\1 13.B. DATE OF BIRTH O~ 87
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Flower Clerk
B. TYPE OF INDUSTRY OR BUSINESS Flowers By Reni
15. PLACE OF BIRTHNew Rochelle. New York
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMEWalter Michael Cohn
B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAME Kathleen Barbara Meegan
B. COUNTRY OF BIRTJJ 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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4. EMPLOYMENT
A. USUAL OCCUPATION Line Service
B. TYPE OF INDUSTRY OR BUSINESS Supermarine
5. PLACE OF BIRTHPOughkeepsie. New York
(CITY. STATE/COUNTRY IF NOT USA)
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6. FATHER
A. NAME Walter John SeiPD
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Linda Carmela Ridolfo
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
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNUUMENT
C. DATE LAST MARRIAGE ENDED? / /
(2) 0 DEATH
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
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
a:
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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 sworn, depose 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 the marriage state. . / . .. I'r
~\ -.u . !!( 'Ai!"-""..Ii c C~
21. SIGNATURE OF GROOM ~ . -- - ~~aURRENT NAME
23. ~~J~T~~~DO~N-?O~~O~~ ~~yBg~:~~E DATE 08/17/2005
This license authorizes the marriage in New York State f the bride and groom named above by any person authorized by New York Domestic
Relations Law !l11 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Jo C. Mast rson
TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ - DATE 08117/2005
"-v-" M~Mfcfa ush Rd, Wappinger Falls, NY 12590
STREET ClTYfTOWN STATE
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27ZTYP F CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND AM
PLACE INDICATED. t:.I ~ PM ~. pE 9 0 OTHER, SPECIFY
--;- /I 1A
29 OFFICIANT"""; tJ S t:, Pi - II A/(7' )' . \
NAME (PRINT) AJ
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YEAR
AM 08
6:02 PM
2005
10
16 2005
18
ZIP
28. PLACE WHERE MARRIAGE OCCU~D ) 'J
T> l/ I t/IJ e .J
A. STATE NEW YORK t.-"COUNTY
17
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF prtOWN OF 0 VILLAGE OF
SPECIFY hJ;f t- / /)
J }/J U/
SIGNATURE~
DOH-98 (11/98)