057
z z
~ g w
~ ~.... 29 OFFICIANT
>- z <( NAME (PRINT)
~ ~ ()
~ g iL
~ u- i=
~ 0 a:
:s ~ w
Iii 0 ()
I- "'
~ ~ NAME (PRINT)
SIGNATURE ..
DOH-98 (11/98)
>-
z
w
CIJ
w
([l
o
--'
:J
o
I
CIJ
5'
;=:
'"
a:
>-
CIJ' _
a
w
a:
w
Cl
'"
c:
a:
'"
::;
u.
o
w
>-
'"
o
ii:
;=:
a:
w
o
w
a:
w
I
;;;
CIJ
CIJ
w
a:
o
o
'"
>-
u.
C3
w
a.
CIJ
a:
w
III
::;
:J
Z
o
z
'"
>-
w
w
a:
>-
Ul
COUNTY Dutches;;
CITYITOWN V'!appinge:
~~J~~C~ 1 366
REGISTER '5-
NUMBER !
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jert\ibtr{ C, Hans~DJilsuRNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.-J
1. A. FULL NAME
11. A. FULLNAME
~ea L. Gj~RRENT SURNAME
FIRST
FIRST
0-
N
e BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Uansmann
(OPTIONAL - SEE REVERSEr
o SOCIAL SECURITY NUMBER 07~ 72-9864
12. RESIDENCE A. N v B. 01 rt,.~
ffrATE) (~
C. CHECK ONE 0 CITY 0 TOWN WVILLAGE
AND
SPECIFY Staatsburg
D. STREET ADDRESS 2JJ57 ROIIte 9 G ZIP 12'580
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 114-64-0202
2. RESIDENCE A. N(S't..TE) 8. Q~ess
C CHECK ONE fiiI- CITY 0 TOWN 0 VILLAGE
AND n "'k .
SPECIFY r-QUgll eepsle
D. STREET ADDRESS 12 Meyer Aven' Ie ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? [jI' YES 0 NO
MO~ /~ /~8
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
McUt /1JJv 4 ~~~
13. A. AGE 2-1
14. EMPLOYMENT
13.B. DATE OF BIRTH
3. A. AGE 26
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Steam Fitter
B. TYPE OF INDUSTRY OR BUSINESS Local 21
5 PLACE OF BIRTH ~~YmE~~F~AX ork
6. FATHER
A. NAME Frank Hansmann
8. COUNTRY OF BIRTH U S ,A.
7. MOTHER
A MAIDEN NAME Palricia ,^,nn Munning
8. 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 USUAL OCCUPATION Teacher's Asst
B. TYPE OF INDUSTRY OR BUSINESS Astor Home For Children
15. PLACE OF BIRTH ~rWrm~~I~rR~ Xlj'rk
16. FATHER
A. NAME Neil Gibb
B. COUNTRY OF BIRTH IJ S A
17. MOTHER
A. MAIDEN NAME Frances Hall
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
DEATH
o
o
o
(2) 0 DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(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
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
w
UJ
Z
W
()
::::;
18T 0 0 1 ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best~f m 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 rriage state. ;;; JJ flJ)r.4..1
21 SIGNATURE OF GROOM ~ t:. < ~~ 22. SIGNATURE O~ BRIDE" Cl.Jlti.1.fJ(i J]) - ~..o
SE CURRENT NAM . US~RRENT NAME
23. ~~JJT~~~Do~N~o~~OJ1: ci;\,Bgr~~~E DATE 00/140004
This license authorizes the marriage in New York State f 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
~
{ SEAL }
'-y-I
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
AM
M
15
2
08
13 2004
06
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY [>v- ~$
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ,,{ TOWN OF 0 VillAGE OF
SPECIFY L;:, r; tf.1I III GE
RELIGIOUS 1 0 CIVIL
9 0 OTHER, SPECIFY
~-h7Y
DATE Ct, - :2~ -64
(2~O
TITLE
STATE
SIGNATURE ..