162
STATE OF NEW YORK I STATE FILE NUMBER
:] Dutchess (THIS SPACE FOR STA TE USE ONL Y)
COUNTY DEPARTMENT OF HEALTH
CITYfTOWN WapplngAr
DISTRICT 1388 AFFIDAVIT, LICENSE and
NUMBER
REGIg'rER 162 CERTIFICATE OF
NUMBER
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FUll NAME lbiff'- M. M~ SURNAME 11. A. FUll NAME 8..~ L ~SURNAME
FIRST FIRST
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 09s..52-4B32
2. RESIDENCE A. ~)YoJ:k B. ~8B8
C. CHECK ONE D CITY D TOWN o.,vlLLAGE
~~~CIFY Wstppi'lgelS Falls
D. STREET ADDRESS 15 Uss Road ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~~M'Z~~~~~e~~SE) MeqJer
D. SOCIAL SECURITY NUMBER 108-58-028C
12. RESIDENCEA. ~ff8rk B. Qulehess
C. X~6CK ONE D CITY D TOWN D ~ILLAGE
SPECIFY 'NappingeFS Fells
D. STREET ADDRESS 16 USs Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? evES D NO
M0fiJ5 / og L,9G1
3B. DATE OF BIRTH
13.B. DATE OF BIRTH
3. A. AGE 33
4. EMPLOYMENT
A. USUAL OCCUPATION Trudc:.DlWer
B. TYPE OF INDUSTRY OR BUSINESS CrotoR D. P. W.
5. PLACE OF BIRTH ~~~vMw.' Yoit'
6. FATHER
A. NAME Hany James Mezger
B. COUNTRY OF BIRTH USA
7. MOTHER
13. A. AGE 42
14. EMPLOYMENT
M
A. USUAL OCCUPATION Nl:JfSC
B. TYPE OF INDUSTRY OR BUSINESS HtIcIson 'Jalley Ilospltal
15. PLACE OF BIRTH 8.,.ksldJL..NI\'\i.~t.III'k
16. FATHER
A. NAME John 1....fJwrena;
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Katherine Mlrle KIvIeky
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. MAIDEN NAME Carol Jat
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o Q
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) D DEATH
1 0 ()
B. HOW DID LAST MARRIAGE END? (3) D"VORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? MONTH 01 / 0.09 / MT
D. ARE ANY FORMER SPOUSE(S) ALIVE? D~S D 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
(3) D ANNULMENT
/ /
1~ D
2ND D
3AD D
4TH D
I, being duly sworn, depose and say, that to the best of my knowledge and
as to my right to enter into the m r 'age state.
21. SIGNATURE OF GROOM ~
D 1ST 01JfJ911997 Wh.'te Plallt$t NtM York 0 q".
D 2ND D D
D ~D 0 D
D 4TH D D
elief that the information I provided is true and that J declare that no ~aJ impediment exists
22 IGNATURE OF BRIDE ~ ~ / ~ ~./..IL .-'
USE CURRENT NAME
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omestic
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State
Relations Law ~11 to perform marriage ceremonies within
D If checked, this license is to
24. TOWN OR CITY CLERK
DATE
of the bride and groom named above by any person authorized by New York
W York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
e used only' for llie. purpose'of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-v-I
NAME (PRINT)
TIME
MONTH
YEAR MONTH
YEAR
TE 1212912003
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
A.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
D CITY OF D TOWN OF ~ VILLAGE OF
29. OFFICIANT
NAME (PRINT)
SPECIFY
~
SIGNATURE ~
DOH-98 (11198)
SIGNATURE