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COUNTY ~
CITYITOWN ::PfAnger
DISTRICT 1
NUMBER
REGISTER 1.09
Nl.. 'R
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Richard A Ml.IBC8t
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Christine M. Jans
MIDDLE CURRENT SURNAME
~
1. A. .FULL NAME
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
11.
N
107.54-4206
B. Dutchess
(COUNTY)
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Muscat
(OPTIONAL. SEE REVERSE) ~"'U:: ":Irft .11750
D. SOCIAL SECURITY NUMBER ~~~
12. RESIDENCE A. New Yark B. nutr.hP.5uL
(STATE) ~
C. CHECK ONE D CITY [JIll'rOWN D VILLAGE
~~CIFY WaDDinaer
STREET ADDRESS 36 Old stIte Road ZIP 12590
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES rI NO
O~ /" AARR
MONTH DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York
(STATE)
C. CHECK ONE D CITY c1'TOWN D VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 36 Old StIte Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES r:! NO
02 / 23 / 1963
MONTH DAY YEAR
13.B. DATE OF BIRTH
D.
E.
13. A. AGE 38
3. A. AGE 41
38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Tradesman
B. TYPE OF INDUSTRY OR BUSINESS Self Employed
5. PLACE OF BIRTH Yonkers, New York
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME PlISqUale ~ MLBCSt
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME lorraine Anne Sereftn
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATION Manaaef'
B. TYPE OF INDUSTRY OR BUSINESS Reeder's Digest
15. PLACE OF BIRTH SaInt Paul. Minnesota
(CITY. STATEICOUNTRY IF NOT USA)
16. FATHER
A. NAME Donald Norman Jans
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Virginia M-.y Gartner
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
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) cfDlVORCE (3) DANNULMENT _IDp_DEATH
C. DATE LAST MARRIAGE ENDED? 03/ 12 / 2002
MONTH.,. DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ITYES D NO
lD. 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
03112/2002 PoughkHpsle. New York D c1'
D
D
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
20. IF PREVIOUSLY DIVORCED OR ANNUl:ED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
D D
D D
D D
D D
ediment exists
D
D
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 marriage in New York State of the bride and groom named above by any person authorized by Ne~ York Domestic
Relations Law ~11 to perform marriage ceremonies hin New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CI~~~ J. M 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
.-'-.
{ SEAL }
'-v-I
ZIP
AM
02:45PM
08
YEAR
TIME
MONTH
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICAT D.
1~
28. PLACE WHERE MARRIAGE OCCUR~
A. STATE NEW YORK B. COUNrv<2'It'1C IfA
C. LOCATION OF CEREMONY
,/
(CHECK ONE AND SPECIFY) /'
D CITY OF D TOWN OF ct'V,LLAGE OF
SPECIFY jAJ~ JA.6 tItS ~
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t=
a:
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NAME (PRINT)
SIGNATURE ~
DOH.98 (11/98)