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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Todd A. ImmesberEr
MIDDLE CURR SURNAME
23. SUBSCRIBED AND SWORN TO BEFORE ME"
SIGNATURE OF TOWN OR CITY CLERK ~ DATE n4/7~l7nn"
This license authorizes the marriage in New York Sta of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl urpose of a second or subse uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY Dutchess
CITYrrOWN Wappinaer
~~J:IfJ 1368
~5~~J~R 46
1. A. FUU. NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 103-60-5536
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York
(STATE) .-J.
C. CHECK ONE 0 CITY LJ"'TOWN
AND W .
SPECIFY 8DD,naer
D. STREET ADDRESS 15 Middlebush Road
B. ~~ess
o VILLAGE
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIu.AGE? 0 YES D' NO
3. A. AGE 31 3B. DATE OF BIRTH nli / (11 / 1Q7
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION E M T
B. TYPE OF INDUSTRY OR BUSINESS Alamo
5. PLACE OF BIRTH ftAineol'-.....onalsland
(CITY, STATE/CouNTRY IF'\liOT USA)
6. FATHER
A. NAME Emillmmesber:ger
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Oor:is Pder:c'...or:l
B. COUNTRY OF BIRTH I' ~ A
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o D
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
II:
W
III
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21. SIGNATURE OF GROOM~
W
en
z
W
o
::;j
~
{ SEAL}
"-v-I
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
DOH-9B (11I9B)
::; I A I t: t-ILt: NUMIft:H
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~:.y Jo.y Wils~RENT SURNAME
11. A. FULL NAME
FIRST
DEATH
n
(2) 0 DEATH
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Wilson - Immesherger
(OPTIONAL. SEE REVERSE) 6
D. SOCIAL SECURITY NUMBER 0 7-74-2356
12. RESIDENCE A. ~XATE) B. ~~ess
C. CHECK ONE 0 CITY 0 "'OWN 0 VILLAGE (CO )
AND W "
SPECIFY .9,nger
D. STREET ADDRESS 15 Middlehush Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIu.AGE? 0 YES D""No
13. A. AGE 2Q 13.B. DATE OF BIRTH n"l / n.. /"D'7A
~
14. EMPLOYMENT
A. USUAL OCCUPATION Un - Fmployt'!d
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Rear-on f\lew Vork
(CITY, S1ATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Mark Wil!lon
B. COUNTRY OF ,BIRTH [I c::: A
17. MOTHER
A. MAIDEN NAME Diana \!OR Hof8
B. COUNTRY OF BIRTH I f S A
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
o
o
o
o
o
o
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
o 0
o 0
o 0
dec are that nD legal impedil"Qent exists
,. .J
TIME
MONTH
YEAR
MONTH
YEAR
11.U\M
""'l>M
26
200
06
24 2003
04
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY J4,7Z'~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF IW"'TOWN OF 0 VILLAGE OF
SPECIFY E"19Sf" FiSIl~/J
:: ~i:
STATE
NAME (PRINT)
SIGNATURE ~