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COUN.TY o.ltcbess
CITYfTOWN wappinger
~~J~~c~ 1368
~5~I~J~R 62
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
M.- stei.RENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL V)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Jmm!fer L R8'lANT SURNAME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
8. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Steiner
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 09Q 79--8821
12. RESIDENCEA. NMEyaFk B. ~
C. CHECK ONE 0 CITY D.;OWN 0 VILLAGE
AND _
SPECIFY '_~JappiRg8r
D. STREET ADDRESS 15L '.MlIte Gate OIWe ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
Mc03 / CM
12590
YES D;NO
~9f12
QSS.14-7493
2. RESIDENCEA. ~)Yor:k B. ~IS8
C. CHECK ONE 0 CITY o;rOWN 0 VILLAGE
AND \A.....
SPECIFY y_ppanger
D. STREET ADDRESS 15l \NhIt4t Gate DrIv.
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE?
3. A. AGE 25 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Tedmici8A
B. TYPE OF INDUSTRY OR BUSINESS I. S. M.
5. PLACE OF BIRTH ~~~If'd
6. FATHER
A. NAME Michael J. steiAer
B. COUNTRY'OF BIR;H USA
7. MOTHER
A. MAIDEN NAME Mary I'.. AeeeFEle
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PRE;VIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
ZIP 12590
o YES WNO
13. A. AGE 2i2
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION Substitute Teeeher
B. TYPE OF INDUSTRY OR BUSINESS Hyde PaFk CfiFI. Seh. 0Ist.
15. PLACE OF BIRTH ~M~, fslj!JFIda
16. FATHER
A. NAME REJbeFt c. Re)'es
B. COUNTRY OF BIRTH U S ^
17. MOTHER
A. MAIDEN NAME Sharon ClZlbeth Lee
B. COUNTRY OF BIRTH U S ^
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
o
o
(2) 0 DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
B. HOW DID LAST 1AARRIAGE 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
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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLlLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say
as to my right to enter into the marr
21. SIGNATURE OF GROOM ~
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
at to the best of my kn wledge and belief that the infgrmation I provided is true and that I declare that no legal impediment exists
estate.
22. SIGNATURE OF BRIDE ~
w
en
z
w
o
::i
23. SUBSCRIBED AND SWORN TO
SIGNATURE OF TOWN OR CI CLERK ~
This license authorizes the marriage in New York and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit 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
~
{ SEAL }
'-.-'
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
YEAR
MONTH
YEAR
TIME
MONTH
08 162004
2B. PLACE WHERE MARRIAGE OCCURRED
06
18
, ATE
27. TYPE OF CEREMONY
oK RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
A. STATE NEW YORK B. COUNTY ~1-J..c,~ ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ):l TOWN OF D VILLAGE OF
SPECIFY .pj~.so.,.jf ~~\e.y
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
~-^-~,.J
G, ~21.o"c'f
~,
TITLE
DATE
Pce(fl..c 0..,,+ \J ca..tJ
ST T
SIGNATURE ~