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COUNTY O! deb.-
CITYfTOWN Wappinger
~~J~~1J 1368
~5~I~J~R 70
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
I
L 0 SUPPLEMENTAL FILE
~
1. A. FULL NAME
~ M. w.mENT SURNAME
FROM THE BRIDE
11. A. FULL NAME FIRST R~ GBI.~NT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Kil&ehner'
C. S~S~~:~M~~~t~~e~~SE)'N8it8
D. SOCIAL SECURITY NUMBER 1>>--4-4 8156
12. RESIDENCE A. NIWlm:k B. Q~~B
C. ~5CK ONE. 0 CITY CVOWN 0 VILLAGE
SPECIFY Pough~e
D. STREET ADDRESS 26 HamptoR Road ZIP 12803
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 47 13.B. DATE OF BIRTH ~ '/~ ~~
14. EMPLOYMENT
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 114050-1020
2. RESIDENCE A'~E;tor:k B. ~ell
C. CHECK ONE 0 CITY [il'TOWN 0 VILLAGE
AND P ...m~
SPECIFY nay~---.-e
D. STREET ADDRESS 26 HlmlXOn Road ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE? 0
3. A. AGE -47 3B. DATE OF BIRTH MJfl / ~~
4. EMPLOYMENIT
A. USUAL OCCUPATION Auto Tecbnici8n
B. TYPE OF INDUSTRY OR BUSINESS Poughkeepsie Ford
5. PLACE OF BIRTH 9H~~ ,:i.
6. FATHER
A. USUAL OCCUPATION Medical Appeals CI8fIc
B. TYPE OF INDUSTRY OR BUSINESS Clre Core NatIonal
15. PLACE OF BIRTH M-.~H<<wu't9'k
16. FATHER
12603
YES ~ NO
/ji66
A. NAME Harald 0 W8ite
B. COUNlTRY'oF BIRTH USA
7. MOTHER
A. MAIDEN NAME Ilelen M. EllA
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. NAME William Kil8Ghn8r
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Peullne St.
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
l' 0 0
B. HOW DID LAST MARRIAGE END? (3) owelVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTH 12 / ~ / 18$3
D. ARE ANY FORMER SPOUSE(S} ALIVE? [ijf'ES 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
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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) SEUF SPOUSE
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o
o
12103f1993 DutGtMIBs CCHIly, NeL'"I
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ent exists
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 Stat 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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
r-I'-,
{ SEAL }
'-v-I
NAME (PRINT)
MONTH
YEAR
YEAR
TIME
MONTH
08
07
01
29 2004
T
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATE
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. couN~fl1"tffs':
C.
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