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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
RobertS.MutBheIer
]
COllNTY Dutch~
CITYfTOWN ::PfAngef
DISTRICT 1
NUMBER
REGISTER 128
NUMBER
1. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 099-56-9145
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York
(STATE) ~
C. CHECK ONE 0 CITY U TOWN 0
AND \NIl.
SPECIFY pplngef
D. STREET ADDRESS e cauaa Lane
ZIP
125&0
YES rI NO
/197
YEAR
B. Dutchess
(COUNTY)
VILlAGE
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0
3. A. AGE 33 3B. DATE OF BIRTH 09 / 06
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Welder
B. TYPE OF INDUSTRY OR BUSINESS Metro North RlllrOld
5. PLACE OF BIRTH Queens, NeW York
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Robert Edward Mulsheler
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME
Kathleen Kuzblk
USA
1
B. COUNTRY OF BIRTH
8. NUMBEF"OF THIS MARRIAGE
B. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1VO'iJE CIVIL ANN~LMENT
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
11. A. FULL NAME
FROM THE BRIDE
Christina J. MDBS
MIDDLE
FIRST
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Mulsheler
(OPTIONAL - SEE REVERSE) 084-70.7237
D. SOCIAL SECURITY NUMBER
12. RESIDeNCE A. New York: B. Dutchess
(STATE) -"IlL (COUNTY)
C. CHECK ONE 0 CITY U"'TOWN 0 VILLAGE
D. ::~~ ~CS:dI LIne ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r:I NO
10 /24 /1970
MONTH DAY YEAR
13. A. AGE 32
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Domestic Engineer
B. TYPE OF INDUSTRY OR BUSINESS
15. ,PLACE OF BIRTH Beacon, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Melvin Mass
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Frances Petterson
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
lB. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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
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
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
nowledge and be ief that the information
23. SUBSCRIBED AND SWORN TO BEFORE ME.
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York named above by any person 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 CITr-<;iLEFjK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) ~ona J. MoIse
{ t) TIME MONTH
SEAL SIGNATURE ~- TE 09I1'Z
MAI:t(1 Mmebush R Falls, NY 12590 AM I't6
'-.-' 03:16M \NI'
STREET !TOWN A
~~~R~~~Ri~~~ 10~0~~~N~~~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR
DATE AND AT THE TIME AND
PLACE INDICATED.
21. SIGNATURE OF GROOM ~
NAME (PRINT)
SIGNATURE ~
DOH-B8 (11/98)
o
o
o
22. SIGNATURE OF BRIDE
IP
l~IVIL
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE ANj,SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
SPECIFY