115
ll.
N
....
z
w
Ul
W
III
C
..J
=>
o
I
Ul
Z
o
~
a:
....
Ul
a
w
a:
w
Cl
<(
a:
a:
<(
::<
u.
o
w
~
()
u:
;::
a:
w
()
w
a:
w
I
~
Ul
Ul
w
a:
c
c
<(
>-
u.
C3
W
ll.
Ul
M5w
tii~~ I-
~ffiz <I:
3dal 0
~~g ii:
z- -
~~15 I-
itOUl a::
0....>- W
w~i5 0
b~'"
Z:::i~
COUNTY DutchesS
GITYfTO\llN pnoer
DISTRICT 1
NUMBER
· REGISTER 115
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Christopher J. Eckbardt, JR.
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Usa M. Bohlinger
MIDDLE CURRENT SURNAME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
ARST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) O:7o;a. I::D-9152
D. SOCIAL SECURITY NUMBER " OI"OJU"
2. RESIDENCE A. New York~ B. Ulster
(STATE)..J (COUNTY)
C. CHECK ONE 0 CITY LJ TOWN 0 VILLAGE
~~~CIFY stone Rill
O. STREET ADDRESS 90 M R08d
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Eckhardt
(OPTIONAL - SEE REVERSE) 122-68-1037
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. DutcheBS
(STATE) ~ (COUNTY)
C. CHECK ONE 0 CITY LrTOWN 0 VILLAGE
D. ::~;AD:~=:~08d ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r!I NO
13.A. AGE 35 13.B.DATEOFBIRTH 12 /19 A968
MONTH DAY YEAR
ZIP 12484
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r1 NO
3. A. AGE 35 3B. DATE OF BIRTH D6 / 04 / 1969
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION SUpervisof
B. TYPE OF INDUSTRY OR BUSINESS Home DeDOt
15. PLACE OF BIRTH Pouahk8eDSle. New York
(CITY, STATEICOUNTRY IF NOT USA)
16. FATHER
A. NAME Henry Franldin Bohlinger
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Jeanlne Pen -e
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
DEATH
o
4. EMPLOYMENT
A. USUAL OCCUPATION su~
B. TYPE OF INDUSTRY OR BUSINESS Home DeDOt
5. PLACE OF BIRTH West Islll). New York
(CITY. STATEICOUNTRY IF NOT USA)
6. FATHER
A. NAME Chri~~ Eckhardt, Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Lenore Balsamo
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 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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
.. 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
0:
W
lD
:;
=>
z
c
z
<(
t;;
W
0:
lii
1ST 0 0
2ND 0 0
3RD 0 0
4TH
,
by New York Domestic
w
UJ
Z
W
o
:J
~
{ SEAL }
'-v-'
TIME
MONTH
YEAR
AM
02:38:>M
09
ZIP
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 OCCURRE~~
A. STATE NEW YORK B. COUNTY .
LOCATION OF CEREMONY
(CHECK ONE A2EC1FY)
0. CITY OF 0 TOWN OF 0
29. OFFICIANT
NAME (PRIN
NAME (PRINT)
SIGNATURE ~
OOH-Q8 /11111R\