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COUNTY .Dulme5C-
~ITYITOWN Wappinger:
DISTRICT 1368
NUMBER
~5~'re~R 110
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~ G ~ENTSURNAME .
:;IAI~ ,"ILot: NUMDcn
(THIS SPACE FOR STATE USE ONL Yi
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
-.l
1. A. FUU NAME
11. A. FUU NAME
FIRST
M~ ~ KJeirtURRENT SURNAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 0790-4802238
2. RESIOENCEA. ~;tcxk B. QmtEl11
C. CHECK ONE 0 CITY Cill'TOWN 0 VILLAGE
AND A .
SPECIFY ~en-.
D. STREET ADDRESS 11 Broeo.vay ZIP 12501
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES riI NO
3. A. AGE 15 3B. DATE OF BIRTH ~ /;11 /~
4. EMPLOYMENT
A. USUAL OCCUPATION Pilat
B. TYPE OF INDUSTRY OR BUSINESS Greenelr Chitter
5. PLACEOFBIRTH~oV.
6. FATHER
A. NAME Rupart'ticler
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Virginia .-f\nn
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 3
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~JN~~~~~~e~~SE;ncler
D. SOCIAL SECURITY NUMBER CJ66.5&-1574
12. RESIDENCEA. N.~cxk B. ~FI
C. CHECK ONE 0 CITY Oll'I'OWN 0 VILLAGE
AND A .
SPECIFY Imeal.
D. STREET ADDRESS 11 ~ ZIP 12501
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES riI NO
13. A. AGE 38 13.B. DATE OF BIRTH M~ / l1v Ai.
14. EMPLOYMENT
A. USUAL OCCUPATION P..ast81 WaJIcBr
B. TYPE OF INDUSTRY OR BUSINESS U. S. Post 0fIIe>>
15. PLACE OF BIRTH ~y.
16. FATHER
A. NAME John Kleinl Jr.
B. COUNTRY OF BIRTH USA .
17. MOTHER
A. MAIDEN NAME DeF8thy CGEIy
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 3
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
200
B. HOW DID LAST MARRIAGE END? (3) DiflIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 11 / ')It / 4)I'IN\
MONTH ill!'l""' ."....
D. ARE ANY FORMER SPOUSE(S) ALIVE? [)liES 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
0511511_ V.'eItdl.w. NMv YoJk 0
11J2812OOO Ki~ NeI.-: Vade rY
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B. HOW DID LA$T MARRIAGE END? (3) [JIIbIVORCE (3) 0 ANNUI,MENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? . 08/ ~ / ~
MONTH DA '
D. ARE ANY FORMER SPOUSE(S) ALIVE? [JIttES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE. OF DECREE PLACE ISSUED' AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATEICOUNTRY.IF NOT USA) SELF SPOUSE
11/1311et2 PoughkMpll~ Nw.' YOlk
~ POl~e, ~JeI.'Vadc:
1ST
2ND
3RD
4TH
I, being y sworn, depose an say, t at to the
as to my right to enter into the ~.
21. SIGNATURE OF GROOM ~
[]If
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE OBf1112OO3
This license authorizes the marriage in New York 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 only for the purpose of a second or subsequent ceremon .
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
SIGNATURE ~-
MAILING ADDRESS
r-I'-..
{ SEAL }
'-v-I
YEAR
MONTH
YEAR
TIME
MONTH
AM
PM
10 2003
08
12
10
A
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY DuNe s
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF IlQ TOWN OF 0 VILLAGE OF
SPECIFY jfm € h I Gt.
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
..--
me
1~ CIVIL
29. OFFICIANT
NAME (PRINT)
f. T J/~R-
P. lf~
NAME (PRINT)
SIGNATURE ~