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COUNTY Dutchess
CITYrrOWN Wappll'\g&f
~~J~f~ 1388
~G~I~J~R 30
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Frlo1nk'.1 RnhP-mt
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.J
1. A. FULL NAME
11. A. FULL NAME s; caR Ro~-I"hz.
FIRST M100CE 101&'. -CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Teitelbaum
c. SURNAME AFTER MARRIAGE ~Qbemi
(OPTIONAL - SEE REVERSEr
D. SOCIAL SECURITY NUMBER 08~ ~&-0202
12. RESIDENCE A. N~D!:k B. ~"8
C. CHECK ONE 0 CITY [],frOWN 0 VILLAGE
~~CIFY Fisbldll
D. STREET ADDRESS 5 fllntrock Road ZIP 12524
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
Mal / 11t 1~
FIRST
B. BIRTH NAME, IF DIFFERENT Filnr.r.n
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 05~~~Q7 4.
2. RESIDENCE A. N~rorlc B. ~~
C. CHECK ONE 0 CITY !!it TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 5 Fllntrook Road
ZIP 1~~~4
YES Ii" NO
/ 1i43
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGE 61 3B. DATE OF BIRTH ~ / ~
13. A. AGE 52
14. EMPLOYMENT
13.8. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Retired
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH ~~~~-NmXprt
6. FATHER
A. NAME Peter Filnr.r.n
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME ROle Quarlno
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS .MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNUUMENT
A. USUAL OCCUPATION SaI_ Repr.eRtatWe
B. TYPE OF INDUSTRY OR BUSINESS E. A aefg" 80M, Inc.
15. PLACE OF BIRTH Q~~~MY"_SA)
16. FATHER
A. NAME Harald Teitelbaum
B. COUNTRY OF BIRTH U $ A
17. MOTHER
A. MAIDEN NAME Ide Friedman
B. COUNTRY OF BIRTH U S ^
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
(2) [j DEATH
(3) 0 ANNULMENT
/ /
o
o
o
o
(2) 0 DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
YEAR
MONTH DAY
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
YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNUUED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST
2ND 0 0 2ND
~ 0 0 ~
4TH 0 0 4TH
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
as to my right to enter into the marriage state. .
21. SIGNATURE OF GROOM ~
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the*ITiage in New York te of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform arriage ceremonies wi - New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
If checked, this license is to be used only for the purpose of a second or subsequent ceremon .
24. TOWN OR CITY CLERK 25. A. SOUEMNIZATION PERIOD BEGINS 25. B. ~~~MA~~B~m~:o
~
{ SEAL}
'-.,,-I
NAME (PRINT)
YEAR
TIME
MONTH
DATE 05J04f2005
AM
09:15 PM 05
04
10 CIVIL
07 02 2005
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYW.,-s'T.
ZIP
, AT
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 'jJ. VILLAGE OF
SPEC~.J::~. &-J-
S
I CERTIFY THAT I SOLEMNIZED
THE M!l:RRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TITLE f e.. } E's +
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
SIGNATURE ~