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COUNTY
CITYrTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
nl1tch~~
WaJ1Ping~r
1368
43
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
SW~ M. Schegijt SURNAME
~
1. A FULL NAME
~pesh S ~~T SURNAME
FIRST
11. A. FULL NAME
FIRST
0.
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 13)..64.3122
2. RESIDENCE A. f\.I V B n. dchess
'~AtE) . IMLlIm'l
C. CHECK ONE 0 CITY 0 Ij/OWN 0 VILLAGE
AND
SPECIFY W$lppin~r
D. STREET ADDRESS 43? All Angel~ Hili Road ZIP 12533
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~~JN~~~~~~~e~~SE) Palel
D. SOCIAL SECURITY NUMBER 131-6B~8101
12. RESIDENCE A W V B nll+cl--"""S
(STATE) . ~I'I~._-
C. X~5CK ONE 0 CITY 0 ijiVWN 0 VILLAGE
SPECIFY Wappinger
D. STREET ADDRESS 432 All Angels Hill Road ZIP 12533
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES D.,l'JO
13. A. AGE 26 13.8. DATE OF BIRTH MOJ.iJ / D1~ / m7
14. EMPLOYMENT
A. USUAL OCCUPATION Registered Nurse
8. TYPE OF INDUSTRY OR BUSINESS Westchester Medical Cntr
15. PLACE OF BIRTH (C~~~F't9'iA)
16. FATHER
A. NAME Charles Richard Scheiterle
8. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Sharon Marie Ztr..~er
8. COUNTRY OF BIRTH U S .A.
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 'll'llJo
/ 8/
MO~ DA1 YE~7
3. A. AGE
32
38. DATE OF BIRTH
4. EMPLOYMENT
A USUAL OCCUPATION PJ,ysician
8. TYPE OF INDUSTRY OR BUSINESS Own BllSiness
5. PLACE OF BIRTH Ic~l-9T~~OU!n~^OT USA)
6. FATHER
A. NAME ~llmAnt PeteJ
B. COUNTRY OF BIRTH India
7. MOTHER
A. MAIDEN NAME Shama Patel
8. COUNTRY OF BIRTH India
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
DEATH
o
o
o
(2) 0 DEATH
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
8. 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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say at t
as to my right to enter into the mar' ge sta
21. SIGNATURE OF GROOM ~
o
o
o
o
o
o
o 0
o 0
o 0
o 0
legal impediment exists
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State 0 the bride and groom named above by any person authorized
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
DATE 05'19/2004
by New York Domestic
~
{ SEAL }
'-v-I
NAME (PRINT)
TIME
MONTH
YEAR
MONTH YEAR
11:1~~
05
20
07 18 2004
28. PLACE WHERE MARRIAGE OCCURRED
CIVIL A. STATE NEW YORK B. COUNTY Dc..lt cie 75
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LLAGE OF
SPECIFY -6- M ~. N " 4
L-
ZIP
"WIT"" =E' . ~
NAME (PRINT) ~:.It!
SIGNATURE ~