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COUNTY ~
CITYITOWN wappinger
~~J~k~T 1368
~5~I~J~R 3
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brian M. Franz
MIDDLE CURRENT SURNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Melissa H. Freer
MIDDLE CURRENT SURNAME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
Q.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Franz
(OPTIONAL - SEE REVERSE) 13~'72 2324
D. SOCIAL SECURITY NUMBER J"'.
12. RESIDENCE A. New York 8.' Dutchess
(ST ATE) (COUNTY)
C. CHECK ONE 0 CITY D~OWN 0 VILLAGE
AND Wa'
SPECIFY pplnger
D. STREET ADDRESS 9 Fowterhouse Road
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) ~n7A_0147
D. SOCIAL SECURITY NUMBER UUU""'t"'
2. RESIDENCE A. New York 8. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY O"TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 9 FOYt1erhouse Road
""';:01'\
ZIP I tIi...x7V
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE ?4 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Handyman
B. TYPE OF INDUSTRY OR BUSINESS A V. R.
5. PLACE OF BIRTH pt"dJtihltAAnde. New Y ark
~FNOTUSA)
6. FATHER
A. NAME Peter H. Franz
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Jo Aftn 1:. t-IlIMMfd
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
ZIP 12590
DYES rfNO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~NO
13. A. AGE ?~ 13.B. DATE OF BIRTH MOJT9 / t~ /1WJR1
14. EMPLOYMENT
A. USUAL OCCUPATION Un-emplQyed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH ~TY~~tmd~~oY ~1;tc
16. FATHER
A. NAME Michael Omendo Freer
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME . EJlnboth Hop' Gllllgher
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
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
_ 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
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 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 th
as to my right to enter into the marriage st~e.' 1 '
21. SIGNATURE OF GROOM ~ ~ 2. SIGNATURE OF BRIDE ~ ·
o 0
o 0
o 0
o 0
impediment exists
w
en
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23. ~~,J..f~~~Do~N-?O~~OJl~ ci'ivB6E~~~~E DATE 01/11fX105
This license authorizes the marriage in New York Sta bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within w 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
~
{ SEAL}
'-v-'
NAME (PRINT)
TIME
MONTH
YEAR
YEAR
....,
SIGNATURE ~
MAILING ADpRESS
AM
12:38'M
01
12
ZIP
STATE
27. TYPE OF CEREMONY
o ~IGIOUS
9 0 OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~N OF 0 VILLAGE OF
SPECIFY ;0(4 )(t 1/
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRE9
lJ t/'i' c.. n '<...1 "
A. STATE NEW YORK B. COUNTY
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
).. Y Or
~ '
....., ./J
TITLE
10 CIVIL
nnl-l.QA 111 lOA'
'1
-
NAME (PRINT)
SIGNATURE ~
SIGNATURE ~