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N
COUNlY Dutchess
CITYfTOWN Wam:~inoer
~~J:IfJ 1363
~5~1~~R 15
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael W. Pultz
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
1. A. FUll NAME
FROM THE BRIDE
Lisa W. Almestica
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME),IF DIFFERENT Wickman
c. SURNAME AFTER MARRIAGE Pultz
(OPTIONAL - SEE REVERSE) 09" 64 0398
D. SDCIAL SECURITY NUMBER t.)--
12. RESIDENCE A. New York B. Dut.chess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY D"10WN 0 VILLAGE
~~~CIFY Wappinaer
D. STREET ADDRESS 5 Paulette lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d'" NO
13.A. AGE 74 13.B.DATEOFBIRTH 17 /71 A~7R
MONTH DAY YEAR
11. A. FULL NAME
RRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 056 501349
D. SOCIAL SECURITY NUMBER - u-
2. RESIDENCE A. New York
(STATE)
c. CHECK ONE 0 CITY D"'TOWN
AND W .
SPECIFY aOPlnoer
D. STREET ADDRESS 5 Paulette lane
B. Dutchess
(COUNTY)
o VILLAGE
ZIP 12590
DYES r! NO
7~ / 1Q74
DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION SUDervisor Teller
B. TYPE OF INDUSTRY OR BUSINESS M & T Bank
15. PLACE OF BIRTH PouahkeeDsi~L New York
(CITY, ST1iTElCOUNTRY IF NuT USA)
16. FATHER
A. NAME Roy Wickman
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME M~rilyn Dnty
B. COUNTRY OF BIRTH I J S'; A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
100
B. HOW DID LAST MARRIAGE END? (3) D"liIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 02 / 13 / 2nO~
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? D~ES 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
n7/1 ~I?nn~ PnlJghkp-p-p!':if!, Nf!W Y nrk 0.... 0
o 0
o 0
o 0
e im~nt xist
E. IS IlESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE ~R 3B. DATE OF BIRTH 11 /
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Tree Trimmer
B. TYPE OF INDUSTRY OR BUSINESS Lewis Tree Company
5. PLACE OF BIRTH Bronlk.f.Jew York
(CITY, STAI~OUNTRY IF NOT USA)
6. FATHER
A. NAME Norman Pultz
B. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A. MAIDEN NAME Joanne Petko
B. COUNTRY OF BIRTH I J S'; A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 OEATH
B. HOV/ DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
C. DA1E LAST MARRIAGE ENDED?
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
1ST
2ND
3RD
o
o
o
o
o
o
21. SIGNATURE OF GROOM ~
23. ~~~:':::=~DO~~O~O~~ ri~6r2~i~E DATE 02/20/2003
This license authorizes the marriage in New York Stat of the person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within w York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used only for the pur ose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
,-'-..
{ SEAL }
'-v-I
YEAR
MONTH
YEAR
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
TIME
MONTH
AM
02:57PM
02
21
200
04
21 2003
ZIP
. STA E
27. TYPE OF CEREMONY
o 2{ RELIGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
'Y,)v..4 JS
A. STATE NEW YORK B. COUNTY -(.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF )( TOWN OF 0 VILLAGE OF
SPECIFY W t:YI7JVl:;-er
STREET
I CERTIFY lHAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10 CIVIL
TIME
3 '3 oJ. 03
~At.?:f~1I~ l< E j T /-) lJv J f) r" L:J H TITLE f-c ~h/~A
SIGNATURE ~ ?~ u "Y -::~--'- ) DATE '2/ oj /t!JJ
MAILlN(PDDRESS 7 / ~ ~d / I J Lj .r /'75"90
/ J- -( 0 Z.Jr'V J '76 !,J '^-:YJ/,JY'(f -er../ .c~J f'I" ,.-.
STREET CITY fTOWN 7""" ./ STATE
30. WITNESS TO CER~NY OCr I tz..
NAME (PRINT) <.J~S6 r') r
NAME (PRINT)
SIGNATURE ~