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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
COUNTY OUtctle-ss
CnYlrowN Wappinger
~~J:k1J 1368
~5~~J~R 1-4'
L A. FULL NAME
~WJW. ~rlTSURNAME
FIRST
a.
N
B, BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 125-7Q..672Q
2. RESIDENCE A. _IYolk B. ~
C. ~~6CK ONE 0 CITY 0 TOWN ~VILLAGE
SPECIFY Wappingem F8.
D. STREET ADDRESS 25 Spring Street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? O;I'YES 0 NO
3. A. AGE 22 3B. DATE OF BIRTH Mom / D~ / y1:981
4. EMPLOYMENT
A. USUAL OCCUPATION Deli Clerk Manager
B. TYPE OF INDUSTRY OR BUSINESS Joe" ItaIlln MI'*-t
5. PLACE OF BIRTH ~,qnlLJJIIv,~ 'i_I
6. FATHER
A. NAME ll1cxA_ SlelfeR R_
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Kethryn Hubner Crandell
B. COUNTRY. OF BIRTH U S ,~
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
l-
S;
ct
C
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DEATH
o 0 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
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
r-
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME
CtuRna M. G~TSURNAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c. S~~~~~rft.~~~~t~~e~~SE)Res
D. SOCIAL SECURITY NUMBER 12Q. 72--8263
12. RESIDENCEA. N!ilWEyeFk B. ~
C. ~~6CK ONE 0 CITY 0 TOWN D,;'ILLAGE
SPECIFY \Happingelll Falls
D. STREET ADDRESS 25 Spring SWIet ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?, ~YES 0 NO
13. A. AGE 13 13.B. DATE OF BIRTH MeGa / 28 "'19fM
14. EMPLOYMENT
A. USUAL OCCUPATION IndependeAt Beauty Censultant
B. TYPE OF INDUSTRY OR BUSINESS MGlry KGy
15. PLACE OF BIRTH ~.IA.-"".: YeFk
16. FATHER
A. NAME 'flA..iam Miehael Goebel
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME RoIeInn Marte DI Marco
B. COUNTRY OF BIRTH U & A
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
" 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 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
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1ST
2ND
3RD
4TH
I, being duly sworn, depose an
as to my right to enter into the
21. SIGNATURE OF GROOM ~f
o 0 1ST 0 0
o 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
y knowledge and belief that the in ormation 1 provided is true and that I declare that nD legal impediment exists
22. SIGNATURE OF BRIDE ~ lJ7;um;"" m ,1J.rr...bR 0
~NMME
23, SUBSCRIBED AND SWORN TO BE RE ME
SIGNATURE OF TOWN OR CITY ClERK~ DATE
This license authorizes the marriage in New York authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit' 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 }
~
NAME (PRINT)
SIGNATURE ~-'
MAILING ADDRESS
TIME
MONTH
YEAR
MONTH
YEAF
ZIP
10
08
TE 1010712003
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
, AT
27. TYPE OF CEREMONY
o ;x('RELlGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
12 06 2003
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY' OI/l-!-t.A
/0 ;1.'1 03
~~~:i~9!~~T (Z <0 B Ell- 'T J<.. . WILSoN
SIGNATURE ~ a u ~ wd- ~
MAILING ADDRESS '-
(0 3 JiL.OC J I'M. Sf-
STREET CITYfTOWN
30. WITNESS TO CEREMONY
TITLE CKHo\..1 ~ ()'(ll cs-r
/D -J 5'-03
,JY Iu-v{
STATE
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ATOW:,OF 0 VIL:^GE OF
SPECIFY r ,~ { h Ie. /1
I
DATE
RJAJ.i/r
~OM~ {NO
SA
NAME (PRINT)
SIGNATURE ~