131
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C,""row1 wa~nger
~D1STRICT 368
.-NUMBER
REGISTER 131
NUMBER
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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
William D. Jansen, JR
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Yi
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE. rb
-Lynn c: Ge
-1
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
B- BIRTH NAME, IF DIFFERENT
C_ SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 087-42.12::16
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) J (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
AND 'a.....
SPECIFY v"applnger
D. STREET ADDRESS 62 Flelastone BoLdevard ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? M
3. A. AGE 53 3B. DATE OF BIRTH 09 /
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Retired
B. TYPE OF INDUSTRY OR BUSINE~!i
5. PLACE OF BIRTlH KIngston, New York
(CITY, STATEICOUNTRY IF NOT USA)
6. FATHER
A. NAME William Donald Jansen, Sr.
B. COUNTRY OF BIRTH USA
B. BIRTH NAME (MAIDEN NAME), IF IillEF..EBfbl'l
.JII(I!M:II
C. S~S~~~~~~~~t~~e~~SE) CJ94..42-3927
D. SOCIAL SEC~'fSrtc 0Ld:d1G2lla
12. RESIDENCE A. (STATE)'; B. (COUNTY)
C. ~~6CK 01lvaPii~.o TOWN 0 VILLAGE
SPECIFY 82 Fieldstone Botllevsrd
D. STREET ADDRESS ZIP
E. IS RESI~E WITHIN LIMITS OF CITY OR INCORPORATEDClrGE? crfJ
13. A. AGE 13.B. DATE OF BIRTH /
MONTH DAY
y,~
YEAR
12590
'12590
.,
Y~~P1~1
YEAR
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14. EMPLOYMENT
Activities Director
A. USUAL OCCUPATION Pel Management
B. TYPE OF INDUW~E~ York
15. PLACE OF BIRTH '
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER Sol Gerb
A. NAME USA
B. COUNTRY OF BIRTlH
7. MOTlHER
17. MOTHER Sarah Shirley Greenfeld
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH 2
lB. NUMBER OF THIS MARRIAGE
A. MAIDEN NAME PrIscIlla Burgess
B. COUNTRY OF BIRTlH USA
8. NUMBER OF THIS MARRIAGE ;,
DEAl)i
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV'fCE CIVIL ANNO-MENT
DEAQ'
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVO~E CIVIL ANN~MENT
.,
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCb7 (3) 0 '~LMENT :2bIXfEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH .; DAY
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, Yi83 ~CITY' S ~Y, 1'i~'iT6USA) SELF spous:,.
12/1611 ~.. .e, N Too 1ST
071101200O ,N Yo'; 0 2ND
o 0 3RD
o 0 4TH
ge and lief that the in ormation I provided is true
4
..
YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORC04 (3) 0 2tfLMENT 1MDEATH
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
(~1.~i;IN"USA) S~FSPO~~
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t Zimpediment exists
E CURRENT NAME 1010412004
1ST
2ND
3RD
4TH
I, being duly swom, depose an say,
as to my right to enter into the ma . ag
21. SIGNATURE OF GROOM ~
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of the bride and groom named above by any person authorized by New York Domestic
W York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
e used only for the urpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
YEAR
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