148
>-
z
w
(/)
W
lD
Cl
...J
::l
o
I
(/)
Z
o
;::
..
II:
>- .
(/)
a
w
II:
w
Cl
..
0:
II:
..
::;
u.
o
w
!;(
()
u:
;::
II:
W
()
W
II:
W
I
:;::
(/)
(/)
W
II:
Cl
Cl
..
>
u.
C3
W
l>-
(/)
ti:i:z
~~~ W
~~1;j ~
>-wZ -
3t3~ ()
~~sl u::
z-
n~~ ;::
[to(/) a:
0>-> W
w~C5 ()
b~'"
Z::i~
COUNTY Dutchess
CITYfTOWN ,. 'tIpplnger
DISTRICT v.
~~~~~~R 1368
NUMBER 146
~ I A I t:. Ut- Nt:.VV YUH~
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE G~OQ.M
..J~ Luge, ~ENT SURNAME
FIRST
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Therey,lJ.ln K~A:NAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
l>-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Katzenberger
C. S~S~~~:,.~~~~t~~e~~SE) lJJgo
D. SOCIAL SECURITY NUMBER OSJ..5Q..8463
12. RESIDENCE A. N(:tTEJ B. q~es5i
C. CHECK ONE D CITY D TOWN D.....llLAGE
~~CIFY Wappingers Falls
D. STREET ADDRESS 6309 Pdn~ Cirelp. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? Dfl'vES D NO
MJiQ /?l /1~
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
'I
053-56-3324
2. RESIDENCEA. ......:l.l B ~ess
''lEUTE) . ~.
C. X~6CK ONE D CITY D TOWN ev-'ILLAGE
SPECIFY VIs.ngem Falls
D. STREET ADDRESS 8309 PFinGeSs Ciu::le
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
ZIP 12590
LViES 0 NO
3. A. AGE 40
4. EMPLOYMENT
3B. DATE OF BIRTH
13.8. DATE OF BIRTH
A. USUAL OCCUPATION PFBduetion Manager
B. TYPE OF INDUSTRY OR BUSINESS SEe
5. PLACE OF BIRTH (~ YfiA)
6. FATHER
13. A. AGE 45
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH ~"'~ Y~~A)
16. FATHER
l-
S;
<
c
u::
""U-
-<
A. NAME John Katzenberger
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Evelyn Bames
8. 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
o
A. NAME Jose Luge
B. COUNTRY OF BIRTH pa;aerte Riee
7. MOTHER
A. MAIDEN NAME Esther Robles
B. COUNTRY OF BIRTH Puerto Rico
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
1 0 0
B. HOW DID LAST MARRIAGE END? (3) 0 oilIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? III ~/ ")'2 / "lOcr7
MONTH IT DA.,...... Y~~
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) D DEATH
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 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
1ST 11/23/1987 DfonKCo., New York D~ 0 1ST D 0
2ND 0 0 2ND 0 D
3RD 0 0 3RD 0 D
~ 0 0 ~ 0 D
I, being duly sworn, depDse and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the marriage state. ~ ~
21 SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~ - \"'\.
, USE CURRENT NAME
DATE 1no?J2003
by New York Domestic
w
en
z
w
()
:J
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of 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
~
{ SEAL }
"-v-I
NAME (PRINT)
YEAR
YEAR
MONTH
TIME
MONTH
1 0f.22I200
11:0t
10
23
312
21 2003
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYJ)".1Cu'.:S
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
;Kl CITY OF D TOWN OF D VILLAGE OF
SPECIFY Pc 0G' t4-k'eLi PSI E..
STRE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1)l( CIVil
NAME (PRINT)
SIGNATURE ~