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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I ma D f'ti~
MIDDLE CURRENT SURNAME
o 1ST 08I2GI1991 PGughkeepsle, Now York 0 ~ 0
o 2ND 0 0
o 3RD 0 0
o 4TH 0 0
ief that the information prOVlded~S tru nd that I declare :hat no legal impediment exists
22. SIGNATURE OF BRIDE ~.Ik&. ~ "....,. L -'/ M.fI~ /..e../I ,
T USE CURRENT NAME n
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in tate of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wi n New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY rkJtc~
CrTYITOWN' w.ppa.,
2~J~~1i 1~
~5~~J~R ,.
1. A. FUU NAME
FIRST
B. BIRlli NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 055-3+7191
2. RESIDENCEA._____lYOrk B. Q~e511
C. CHECK ONE 0 CrTY OiI'I'OWN 0 VILLAGE
AND \AIR.
SPECIFY PP"QP-"
D. STREET ADDRESS 2513 Rot. 90
ZIP 12590
o YES cYNO
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE?
3. A. AGE 61 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Engingeer
B. TYPE OF INDUSTRY OR BUSINESS VllSlllf 8JOtbe1S Medical
5. PLACEOFBIRTH_VOrk
6. FATHER
A. NAME LaLlis DaLlgllIB Diehl
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Katherln. Marl. H.rrlng
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 4' ,
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
, 0 0
B. HOW DID LAST MARRIAGE END? (3) OIilIIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONlli or DA~ 9 / ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? D~S 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOUOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTli, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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11J3Qf197-3 Gosh.A, New YGFk
Q6J3OI19B1 P8ughk8epBie, New YDFIc
03l19QQ04 PCH:Ighk8epBi8, Nay Y 8Fk
21. SIGNATURE OF GROOM
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{ SEAL }
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N/lME (PRINT)
SIGNATURE ~
OOH-98 (11I9B)
I
STATE FILE HUM"""
(THIS SPACE FOR STATE USE ONLY)
Lo
~
SUPPLEMENTAL FILE
FROM THE BRIDE
~mpnie A s~ SURNAME
11. A. FULL NAME
FIRST
B. BIRlli NAME (MAIDEN NAME), IF DIFFERENT Y BRkDnis
C. SURNAME AFTER MARRIAGE Diehl
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 169--40-9704
12. RESIDENCE A. ~E;todc B. ~al
c. CHECK ONE 0 CITY 0 "oWN 0 VILLAGE
AND Wa.
SPECIFY ppnger
D. STREET ADDRESS 2513 Ro'Jte 90 ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0
13. A. AGE !Hi 13.B. DATE OF BIRTH MOQ~ / ~
14. EMPLOYMENT
A. USUAL OCCUPATION Un ~ imployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH (~_t.,~-*~nll
16. FATHER
A. NAME ChaR. YsnkBRis
B. COUNTRY OF BIRTH U & A
17. MOTHER
A. MAIDEN NAME MI. runcll
B. COUNTRY OF BIRTH U S ,A,
lB. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
12590
YES D,.INo
/1~
DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) 0 ....ORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? ^flII/ ~ / ..u:IICIA
MONTH ..... oJlllltl:y y~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 ~S 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
TIME
MONTH
YEAR
MONTH
YEAR
06 05 2004
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF l:'/ VILLAGE OF
SPECIFY W
04
07
SIGNATURE ~