085
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
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MIOOLE CUF!RENT SURNAME
r-.. coL1TY r)lltches~
CITY/TOWN Wappinaer
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1. A. FULL NAME
FIRST
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL> SEE REVERSE)
o SOCIAL SECURITY NUMBER 132<36.735:;>
2 RESIDENCE A. N Y B Dutchess
(STATE) (COUN'\'Yi
C. CHECK ONE D CITY r!! TOWN D VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 16 Dennis Road ZIP 12590
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VILLAGE? DYES 1!1' NO
04 /11 /1~7
MONTH OA Y YEAR
3. A. AGE 57
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Accountant
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH Broaldvn, New Yark'
(CITY. STA'itiCOUNTRY IF NOT USA)
6. FATHER
A. NAME James Y ardley
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME t ~ IcllI~ \Ni'~()n
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) r::! DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 04 / 22 / 1995
MONTH OA Y YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? [fYES D 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
04/22/1995 San Diego. California
DEATH
o
:; I A I I: ~ILt: NUMtlt:H
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
, 1. A. FULL NAME FIRST ~~~![la Gonye~RRENT SURNAME
B BIRTH NAME (MAIDEN NAMEI, IF DIFFERENT Osterc
C. SURNAME AFTER MARRIAGE Yardley
(OPTIONAL> SEE REVERSE) ~ 49
o SOCIAL SECURITY NUMBER 127.. 38- 1 8
12 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~~CIFY Clinton
o STREET ADDRESS 18 Fifth Avenue ZIP 12572
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VILLAGE? DYES f!'l' NO
13. A. AGE ~ 13.B. DATE OF BIRTH 09. /:;>4 )(Q47
MONTH OA Y YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Legal Secretary
B. TYPE OF INDUSTRY OR BUSINESS Teahan & Constantino
15. PLACE OF BIRTH Beacon. New York'
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Frank' H. Osterc
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Bertha C Bachmann
B COUNTRY OF BIRTH Germany
1B. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
1
(3) D ANNULMENT' (2) ~EATH
/2003
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED? 06 / 18
MONTH 'pAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES Cl 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
YEAR
D r:I 1ST
D D 2ND
D 0 3RD
D 0 4TH
and belief that the information I provided is true
D
D
D
07/29/2004
TIME
MONTH
YEAR
DATE 0712912004
n er Falls NY 12590
CITYITOWN STATE
27. TYPE OF CEREMONY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
ZIP
08:43AM
PM
07
o J;8: RELIGIOUS
9 D OTHER, SPECIFY
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY /)v;c;tff~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF ilr TOWN OF D VILLAGE OF
SPECIFY F (SH ~ ILl....
j( :0 "8
~~t~n~~~~T '?- E VI J 0 H JJ }.//. Y D U j..J C:::,
SIGNATURE~ ~.ev ~ M \.;{~
MAILING ADDRESS ~
(",,00 etlJi'F- S-~ FI'>H Il.l...
STREET CITY/TOWN
30. WITNESS TO CEREMONY
TITLE 'PitS "TO 12-
DATE ?, / I '-I/O '{
I /
.AJV
STATE
NAME (PRINT)
12~'2..,-/
31.
SIGNATURE ~