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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert A. HeveSl,
MIDDLE CUR NT SURNAME
o 1ST
o 2ND
o 3RD
o 4TH
lie that the Information I provided IS true
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St e of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies withi New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the u ose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY Dutchess
ClTYrrOWN Wappinger
~~~~~ 1368
~5~~R 45
1. A. FUU NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 080-68-9633
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. CfRm'ecticut B. ~) Haven
c. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
;~CIFY New Haven
D. STREET ADDRESS 16 Mechanic street Apt. 1
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VilLAGE?
3. A. AGE :\R 3B. DATE OF BIRTH
ZIP 06511
D"'vES 0 NO
M
4. EMPLOYMENT
A. USUAL OCCUPATION Lawyer
B. TYPE OF INDUSTRY OR BUSINESS Fdur.ation
5. PLACE OF BIRTH POlJohkeensieL Np.w York
(CITY ,S'i'lhEJci5Uiiil'RY IF NuT USA)
6. FATHER
A. NAME Richard Heverly
B. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A. MAIDEN NAME Oor:otAy PoplOR
B. COUNTRY OF BIRTH II ~ 4.
8. NUMBER OF TI-IIS MARRIAGE 7
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 n 0
B. HOW DID LAST MARRIAGE END? (3) c:rlJIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTH 11 / DJ~ / B''l
D. ARE ANY FORMER SPOUSE(S) ALIVE? D..;'ES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNUlED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (CITY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
11'1517""7 Rensselaer County, NY
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en
1ST
2ND
3RD
4TH
I, being duly swam, depose and say, that to the
as to my right to enter into the marriage stat
[]V'
21. SIGNATURE OF GROOM ~
W
en
z
W
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{ SEAL }
'-..t-I
NAME (PRINT)
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Meike AndreA Wolff
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE HevArIy
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUM8ER 1147 _Il4-R75R
12. RESIDENCE A. C(~T9Rf!r.tiClJt B. ~mJrv';'lRVP.n
C. CHECK ONE Ql'CITY 0 TOWN 0 VILLAGE
AND N H
SPECIFY ew aven
D. STREET ADDRESS 76 MechAnic ~reet Apt 1 ZIP nR511
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? o'vES 0 NO
13. A. AGE )0 13.B. DATE OF BIRTH MOJ;Q / ~~ /1i1,
14. EMPLOYMENT
A. USUAL OCCUPATION Tp..AchAr
B. TYPE OF INDUSTRY OR BUSINESS Edt,cation
15. PLACE OF BIRTH ~w~Si~)
16. FATHER
A. NAME KIAII~ _ niP.tAr W,,1ff
B. COUNTRY OF BIRTH Germany
17. MOTHER
A, MAIDEN NAME , Marget Ueng
B. COUNTRY OF BIRTH Gennany
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
o
(3) 0 ANNULMENT
/ /
YEAR
MONTH DAY
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
o
o
22. SIGNATURE OF BRIDE ~
TE 04/2412003
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
04
25
200
06
23 2003
DAY
YEA
A
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
.,
.z003
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
DOH-9B (11I9B)
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COu~ur(\olUS
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFY l.)~ff".jQ.1\& FA.l.Ls
STATE
NAME (PRINT)
SIGNATURE ~