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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~ard J. ~NTSURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY o.ltcb~
CI1YfTOWN 'Wappinger
DIS rRICT 1368
NUMBER
~5~~l~R 130
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
J..8. SeA_NT SURNAME
1. A. FUll NAME
11. A. FULL NAME
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D: SOCIAL SECURITY NUMBER
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~(M~~~~~e~~SE) V'Aese
D. SOCIAL SECURITY NUMBER 1214~3131
12. RESIDENCE A. ~YClFk B. ~B
C. CHECK ONE 0 CITY D-'OWN 0 VILLAGE
AND
SPECIFY '.N8Bhingtan
D. STREET ADDRESS 118 Kllleam Road ZIP 12545
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Q;'NO
13. A. AGE 24 13.B. DATE OF BIRTH Mc05 / 11 ~Qlr9
14. EMPLOYMENT
A. USUAL OCCUPATION PhannllGiBt Tech. & Ii. M. T.
B. TYPE OF INDUSTRY OR BUSINESS C V "
15. PLACE OF BIRTH ~~.,*'YA~0Fk
16. FATHER
A. NAME Frederick Qeorge Senkbeil
B. COUNTRY OF BIRTH U" A
17. MOTHER
A. MAIDEN NAME Angel. Medugno
B. COUNTRY OF BIRTH Italy
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE . CIVIL ANNULMENT
OB3-~1G1
2. RESIDENCE A. .IYOJk B. QutPB
C. X~5CK ONE ~CITY 0 TOWN 0 VILLAGE
SPECIFY aellcon
D. STREET ADDRESS 19 'Nest Mlln Street
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIlLAGE?
3B. DATE OF BIRTH
ZIP
3. A. AGE 30
4. EMPLOYMENT
A. USUAL OCCUPATION Ne\llf YOJk state TfDDPBI'
B. TYPE OF INDUSTRY OR BUSINESS CrlmlAII Justice
5. PLACE OF BIRTH __ ~IIW' Xprk
. "'rl U
6. FATHER
A. NAME Richlud Wiese
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAlDEN NAME Be_F. .~.nA Sender
B. COUNTRY OF BIRTH U" A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
DEATH
o
(2) 0 DEATH
DEATH
o 0
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE..
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
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21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEFORE ME.
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York S person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies with New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl ur ose of a second or subsequent ceremon .
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-v-I
NAME (PRINT)
TIME
MONTH
YEAR
MONTH
YEAR
09
~
11
22 2003
28. PLACE WHERE MARRI~ED
A. STATE NEW YOR.t';~
C. LOCATION OF CEREMONY
(CHECK ONE AND S~Y)
o CITY OF ~NOF 0
SPECIFY A-,1,t; /.