017
J
0..
N
)1
\ .
, ./
~~~
1-;:1-
ll!~~
I-WZ
CIl...J::l:
:JUW
::l:Cl5
~~cn
G~~
tta(/)
01->-
W~C3
6~'"
Z::::i~
COUNTY Dutchess
CITYITOWN W~mpinaer
~~J:~cJ 1368
~5~I~J~R 17
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael A. Waaner
MIDDLE CURRENT SURNAME
FIRST
I
:JIAIC riLe Numacn
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ctvstal L. Chase
MIDDLE CURRENT SURNAME
.-J
1. A. FUll NAME
11. A. FUll NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 055-4'1-4996
D. SOCIAL SECURITY NUMBER -
2. RESIDENCEA. 1"f~~)York B. ~!-g,~ess
c. CHECKONE 0 CITY 0 TOWN D"'VILLAGE
~~~CIFY WaDDinaers Falls
D. STREET ADDRESS 120 Channinaville Road Apiif' 12590
E. IS RESIDENCE WITHIN-UM~ OF CITY OR INCORPORATED VILlAGE? D"'YES 0 NO
3. A. AGE '>,1 3B. DATE OF BIRTH ?
4. EMPLOYMENT
A. USUAL OCCUPATION RailroadCQnduclof
B. TYPE OF INDUSTRY OR BUSINESS Metro North
5. PLACE OF BIRTH Yonkers.. New York
(CITY,STATElCOUNTRY IF NOT USA)
6. FATHER
A. NAME Richard Wagner
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME P~m~l~ n€!lI~ VE!nnp.ri
B. COUNTRY OF BIRTH I J ~ A
8. NUMBER OF THIS MARRIAGE :2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 n
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Waqner
(OPTIONAL - SEE REVERSE) 077 7") 0110
D. SOCIAL SECURITY NUMBER ' - , e.-u
12. RESIDENCEA. New York B. Dutchess
(STATE) J (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN D"'VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 120 Channingvifle Road Ap:~1f 12590
- ,. .;'
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES 0 NO
I: 13. A. AGE 24 13.B. DATE OF BIRTH 05 / 19 .1'1918
MONTH D~ Y~R
14. EMPLOYMENT
A.LJSVA.L QQgLJPATION Nurse
B. TYPE OF INDUSTRY OR BUSINESS OldchessUialvsis
15. PLACE OF BIRTH Pouahkeepsie. New York
(CITY, STATElCOUNTRY IF NOT USA)
16. FATHER
A. NAME James Chase
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Dollie Morrison
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
:J
Z
C
Z
<(
I-
W
W
a:
ti;
B. HOW DID LAST MARRIAGE END? (3) D"6IVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? nv OR / 1999 C. DATE LAST MARRIAGE ENDED? / /
MONTH ...L DAY Y~R MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 TES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, Y~R) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
Q'3I08/1999 \tVhite Plains, Np.w York 0 0"; 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
e and belief that the in ormation I provided is true an that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ (1, /1~ /7 /l_Q..O ~
~ECUR~
23. SUBSCRIBED AND SWORN TO BEFORE ME 02/27/2003
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage tate of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wi in New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the urpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
YEAR
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say,
as to my right to enter into the marri
21. SIGNATURE OF GROOM ~
w
en
z
w
o
::J
~
{ SEAL }
'-y-I
NAME (PRINT)
TIME
MONTH
YEAR
AM
01 :28M
02
28
28. PLACE WHERE MARRIAGE OCCURRED I A- J
A. STATE NEW YORK B. COUNThll/1LJ.1
C. LOCATION OF CEREMONY
(CHE9<"'ONE AND SPECIFY)
~TY OF 0 TOWN OF 0 VILLAGE OF
SPECIFy~V<;t ~ ~)-c.-
!
CIVIL
fL..
NAME (PRINT)
SIGNATURE ~