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1. A. FUll NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST <iMV' M. KrSmI(NT SURNAME
I
I
COUNTY o.ltcb~
CITYrrOWN Wappinger
~ISTRICT 1388
"~UMBER
~5~~J~R 55
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
AlI_ R. ~~SURNAME
~
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 089--5&-12&1
2 RESIDENCEA'~)YQr:Ic B. ~88B
C. CHECK ONE 0 CITY ~OWN 0 VILLAGE
AND tAt-.
SPECIFY v_pplRger
D. STREET ADDRESS 84 Creek Road ZIP 12GeO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 29 3B. DATE OF BIRTH MoJ2 / ~3 / yt&74
4. EMPLOYMENT
A. USUAL OCCUPATION Firefighter
B. TYPE OF INDUSTRY OR BUSINESS Nev.' Y 0Fk Ctty
5. PLACE OF BIRTH -iQ~~_.: YeFk
6. FATHER
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~\'ifN~'Z~~~:~~e~~SE)Kramer
D. SOCIAL SECURITY NUMBER 12Q.. 7~337-o
12. RESIDENCE A. NMEY8Fk B. ~
C. ~~5CK ONE 0 CITY D..IOWN 0 VILLAGE
SPECIFY Wappinger
D. STREET ADDRESS 84 CFeelE Roed ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES q" NO
13. A. AGE 23 13.B. DATE OF BIRTH M. / 'ZJ ~IIIO
14. EMPLOYMENT
A. USUAL OCCUPATION MCII'IgBgc:. r'racessar
B. TYPE OF INDUSTRY OR BUSINESS II. v.r. C. U.
15. PLACE OF BIRTH BouIftI_,.le~~' York
16. FATHER
A. NAME GlenA Michael KFamer
B. COUNTR'll'OF BIRTH U S ^
7. MOTHER
A. NAME John JaBeph Fitzpatrick
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Corinne Merle GysIn
B. COUNTRY OF BIRTH U S ^
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. MAIDEN NAME Unda Jean Jaked
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
MONni OAY 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
o 0
o 0
o 0
o 0
lare that no legal impediment exists
MONni OAY 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
1ST
2ND
3RD
4TH
I, being duly swom, depose and say, t at t
as to my right to enter into the marri e te.
21. SIGNATURE OF GROOM ~ '
22. IGNATURE OF BRIDE ~
W
en
z
W
o
::i
above by any person authorized by New York Domestic
for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-v-'
YEAR MONTH
NAME (PRINT)
YEAR
TIME
MONTH
06f08I2004
AT ZIP
27 TYPE OF CEREMONY
o RELIGIOUS 1 0 CIVIL
9 0 OTHER, SPECIFY
06 09 08 07 2004
28. PLACE WHERE MARRIAGE OCCURRED . /
A. STATE NEW YORK B. COUNT'(--V0C.h~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 .,;;tF;r VILLAGE OF
sptirt~~ "1/~tr6t1I1iT~
S
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)
SIGNATURE ~