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STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY Dutchess
CITYfTOWN wappinger
'DISTRICT 1356
NUMBER
REGISTER 122
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael A. Parker
MIDDLE
CURRENT SURNAME
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sandra L Schneider
..J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
MIDDLE
CURRENT SURNAME
0-
N
B. BIRTH NAME. (MAIDEN NAME), IF D~~
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) ~3-7~2967
D. SOCIAL SECURITY NUM~E.R . ~__..
12. RESIDENCEA. New york B. DuawKiaD
(STATE)"; (COUNTY)
C. ~5CK ONE P . ~vill'_t2JOWN 0 VILLAGE
SPECIFY ouv..~e
D. STREET ADDRESS 15 DelbBtso Boulevard ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? .~
13. A. AGE 33 13.B. DATE OF BIRTH 01 / 0
MONTH DAY
14. EMPLOYMENT
A. USUAl OCCUPATION Executive Assistant
B. TYPE OF INDUSTIl..'G.9il!l.!:!SlliIiSS ~ Curve CaJiltil
15. PLACE OF BIRTH b'llllel1lS1ana. New york
(CITY, STATEICOUNTRY IF NOT USA)
16. FATHER
.;: NAME Howard Schneider
B. COUNTRY OF BIRTH U & A
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) . Q95..66-5147
D. SOCIAL SECURITY NUMBER
New York
~:8~~:N
16 Oe1b1a1so BoUlevard
2. RESIDENCE A.
C. CHECK ONE
AND
SPECIFY
D. STREET ADDRESS
B Dutchess
. (COUNTY)
o VILLAGE
ZIP 12590
",
J:!. YES 0 NO
III / 1
DAY YEAR
.,
Y/fu7~
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 36 3B. DATE OF BIRTH 06 /
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Chef
B. TYPE OF INDUSTaLq~~li~E2L. Chamere1le Restaurant
5. PLACE OF BIRTH l"aUgrI~e. Ne'N yone
(CITY. STATElCOUNTRY IF NOT USA)
6. FATHER
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A. NAME Gary Parker
B. COUNTRY OF BIRTH U 6 A
7. MOTHER
A. MAIDEN NAME Frances Pletropalo
B. COUNTRY OF BIRTH U ~A
8. NUMBER OF THIS MARRIAGE
17. MOTHER
A. MAIDEN NAME ~et Bros
B. COUNTRY OF BIRTH A
18. NUMBER OF THIS MARRIAGE 2
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1VO~CE CIVIL ANN'j)MENT
"
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORC01 (3) 0 ~~LMENT 2&8iEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR MONTH" DAY YEAR
O. ARE ANY FORMER SPOUSE(S) AliVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 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 (~~Y~ ~ IF..~~~ ~~l"ork SELF SPOUSE
o 0 1ST Uln""-~ · t-.w Too .;
o 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
nowledge and belief t at the Information I provided is true and t gal impediment exists
..
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORlf CIVIL ANNUbMENT
DEAT&
DEAT6
1ST
2ND
3RD
4TH
I, being duly swom, depose and say, that to the bes
as to my right to enter into the ma~2e stal. . I
21. SIGNATUREOFGROOM~ ,,~,
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the 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~RK J .A__ 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) \;jIDI18. --..
SEAL SIGNATURE ~ --" - TE
MAIL2b'MIlIIebuBh R Falls. NY 12590
'-.t-I
. SIGNATURE OF BRIDE ~
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YEAR
STR ET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
AT
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
ZIP
l~IVIL
PM
29. OFFICIANT
NAME (PRINT)
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE A" SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY
NAME (PRINT)
SIGNATURE ~