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COUNTY f)lrt~h~~
CITYfTOWN W#tppinger
~~J~~~ 136R
~5~~l~R 161
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MP-Ivin ~ RlAnd
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~~~Jnyt'.e Mn~!~~RNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
a.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Kreh!:ter
c. SURNAME AFTER MARRIAGE Rland
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 087 -~~?5
12. RESIDENCE A. N v B. nlJtl'h~c;.
(S'i'iiTE) (coum'Yi
C. CHECK ONE 0 CITY 0 rioWN 0 VILLAGE
AND W .
SPECIFY appnger
D. STREET ADDRESS 1 Harbor Hili Road ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE 41 13.B. DATE OF BIRTH ~ / ?l
12590
YES ~NO
/1~
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
Z?~13-64;>?
2. RESIDENCE A. M V B n. dl'hesc.
'(!;TtTE) .~'
C. CHECK ONE 0 CITY OlIltOWN 0 VILLAGE
AND
SPECIFY W9ppin~
1391 Route 378
D. STREET ADDRESS
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 40 3B. DATE OF BIRTH
ZIP 12590
DYES D"'NO
~
:>
<C
C
u:
u.
~<C
4. EMPLOYMENT
A. USUAL OCCUPATION Alrtnmnlive Technician
B. TYPE OF INDUSTRY OR BUSINESS MMdowIantk
5. PLACE OF BIRTH (m!WJ1~9ns.y"~~5i~
6. FATHER
A. NAME .JAm~ M RlAnd
B. COUNTRY OF BIRTH LJ S A
7. MOTHER
14. EMPLOYMENT
A. USUAL OCCUPATION DQg Groomer
B. TYPE OF INDUSTRY OR BUSINESS SeIf-emplQyed
15. PLACE OF BIRTH Fort Bennino. Georgia
(CITY, STATElCOUNTR""'NOT USA)
16. FATHER
A. NAME James John Krebser
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME
A. MAIDEN NAME Balbera Ann Wefford
B. COUNTRY OF BIRTH L J S A
2
louise Coleman
B. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 2
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) 0 1!\'VORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 05/ 01 / 2000
MONTH DAY YEAR
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
0'; 1ST 05101/2000 POllgb~e. N v 0 0';
o 2ND 0 0
o ~D 0 0
o 4TH 0 0
d belief that the information I provi ed is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE" ~ ~ ,(;- ~ J O",.J-,(Il'::~
~~E~1.
DATE 12/2312003
named above by any person authorized by New York Domestic
VALID IN NEW YORK STATE ONLY.
o cond or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) D,nVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? M/ ~ /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 ~S 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
06130I2OO3 Pougbkeepsle, N Y
DEATH
o
DEATH
o
(2) 0 DEATH
?Om
YEAR
21.
23.
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z
w
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::i
12
~
{ SEAL }
'-v-I
TIME
MONTH
YEAR
ZIP
AM
03:11'M
1~CIVIL
28. PLACE WHERE MARRIAGE OCCURR~
A. STATE NEW YORK B. COUNTYJ>\)+t~S5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF >> TOWN OF 0 VILLAGE OF
SPECIFY fO\JC]btffp~\ e.
STREET CITYITOW.
30. WITNESS TO CEREMONY
..."",,'" L~~ D. Darrer
~J),~
l.o\.JW...t J...,
DATE / /;1./6;,'
IV'! I
STATE