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COUNTY Dutchess
CITYfTOWN WapDinger
~~J~~1i 1368
~5~~J~R 31
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Edward Hafemann
MIDDLE CURRENT SURNAME
I
STATE RLE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sativa Haskell
MIDDLE CURRENT SURNAME
1, A FUll NAME
11. A FYLl NAME
FIRST
FIRST
..
N
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE Hafemann
(OPTIONAl- SEE REVERSE) 563-63-5227
0, SOCIAL SECURITY NUMBER
1~, RESIDENCE A, New York B, Dutchess
(STATE) J (COUNTY)
C, CHECK ONE 0 CITY 0 TOWN 0 VILlAGE
~~~CIFY Hyde Park
0, smEET ADDRESS 1! Franklin Road
12538
e, BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl - SEE REVERSE) 128-62 1602
D. SOCIAL SECURITY NUMBER - 0
.2. RESIDENCE A, "i'M) York B. ~~hesS
C. CHECK ONE 0 CITY DwtoWN 0 VILlAGE
;~CIFY Pouahkeeosie
D. . smEET ADDRESS 1782 South Road #2
. E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE?
3, A. AGE 'J,7 3B, DATE OF BIRTH 0"), /
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Contractor
B. TYPE OF INDUSTRY OR BUSINESS Self - Employed
5. PLACE OF BIRTH (~Q~'&~mJ~~
6. FATHER
A. NAME Edward Hafemann
B. COUNTRY OF BIRTH I , S A
7. MOTHER
ZIP 12590
o YES 0"00
11 / 1Q6
DAY YEAR
liP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES 0 ~NO
13, A, AGE 24 13,B. DATE OF BIRTH 12 / 01 /1918
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Artist
B. TYPE OF INDUSTRY OR BUSINESS Self - Em ploved
15. PLACE OF BIRTH Palm Sprinas. California
(CITY. STATEICOUNTRY IF NOT USA)
16. FATHER
A. NAME Richard Haskell
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME I ur..ia \.arrillo
B. COUNTRY OF BIRTH Columbia
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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A. MAIDEN NAME Ro~em sry SIIIlb.t8n
B. COUNTRY OF BIRTH I , ~ A
8. NUMBER OF THIS MARRIAGE ,
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 n
B. HOW DID LAST MARRIAGE END? (3) 0 "rVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 1 ,y ~n /
MONTH ..J DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 TES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULlED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
1DOO/2002 POllgl1ke~psi~, I\I~\IV Vnrk 0 ~ 0
o 0
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e an
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) SEUF SPOUSE
o
o
o
o
DEATH
o
(2) 0 DEATH
,nn,
YEAR
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23. SUBSCRIBED AND SWORN TO BEFORE ME.
SIGNATURE OF TOWN OR CITY CLERK.
This license authorizes the marriage In New York S te 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 onl for the u ose of a second or subse uent ceremon .
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
03/28/2003
DATE
by New York Domestic
~
{ SEAL }
~
NAME (PRINT)
SIGNATURE. .
MAILING ADDJ;lESS
YEAR
TIME
08:39'l
PM
03
29
20305
27 2003
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
27. TYPE OF CEREMONY
00 RELIGIOUS lC"CIVIL
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~ ~ ,^es
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY II JO \'f' ~..p.V-