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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Pel$[o&J1en HottfIDfR~ SURNAME
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD D 0
4TH 0 0 4TH D 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the marri e state.~
21. SIGNATUREOFGROOM~ -1M..A~ f-. ~ ~_
r' '., USE CURRENT NAME ~
DATE 06/250004
This license authorizes the marriage in 'New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New 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
COUNTY Dj rtchess
CITYfTOWN Wappinger
~~~~~c~ 1368
~5~I~l~R 67
1. A FUll NAME
FIRST
0-
N
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCiAL SECURiTY NUMBER 06.2-44-1124
2 RESIDENCE A. N. I B.
(!:'I'ATE)
C. CHECK ONE 0 CITY
AND
SPECIFY Haddon
D STREET ADDRESS ?Q? N~ .Ie~y Avenue ZIP 08108
E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES Ii!' NO
MJM /~ /1W3
~n
~ TOWN D VILLAGE
3. A. AGE 41
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Engineer
B. TYPE OF INDUSTRY OR BUSINESS Lockheed Martin
5 PLACE OF BiRTH ~~IfID~~W~ N(~.tX)
6. FATHER
A. NAME H~!'lS Gllnttler J.tottp-nrott
B. COUNTRY OF BIRTH Germany
7. MOTHER
A. MAIDEN NAME Rita Carol Jaeger
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
o 0
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
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
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Ma~II~."E Van Z.ut~'lr!r SURNAME
~
11 A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE HCJtlenrott
(OPTIONAL. SEE REVERS~
D. SOCIAL SECURITY NUMBER 131-52--5709
12. RESIDENCE A N v B. DI ri,..h~i
WTATEJ ~
C. CHECK ONE 0 CITY ~TOWN 0 VILLAGE
~~~CIFY 1 Inion \'ale
D. STREET ADDRESS 16 On-the-green ZiP 12585
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 40 13.B. DATE OF BIRTH ,,QJH /2gy 1~.A
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Arlington Cntrl Sth Dist
15. PLACE OF BIRTH ~~~~~'N~uXJ
16. FATHER
A. NAME Charles Francis Van Z,llphen
B. COUNTRY OF BIRTH II S A
17. MOTHER
A. MAIDEN NAME Patricia .4.nn Tate
B, COUNTRY OF BIRTH USA
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES D 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
23.
"l
STATE
27. TY~F CEREMONY
D ff'RELlGIOUS
9 0 OTHER, SPECIFY
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NAME (PRINT)
29. OFFICIIINT
NAME (PRiNT)
TITLE
TIME
YEAR
MONTH
MONTH
YEAR
ZIP
10:56AM 06
PM
24 2004
26
2
08
1 D CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT'JWC~SS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~GE OF
SPECIFY vJItf1PtN6G".e5 r:/tU.-~
K. (, !i(r6r
~/7/;;tf
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/c26-C; IJ
31.
NAME (PRINT)
SIGNATURE ~