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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Richard A. Michels
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D~ORCE CIVIL A~ULMENT
.,
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT 0) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 01 / 03 /20 1
MONTIill' 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 PIJ\CE ISSUED AGAINST WHOM
JMONTH, DAY, YEARL (CITY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
1ST u8129/1984 ~oughkeepsie, New York 0 S
2ND 01103/2001 Poughkeepsie, New York 0 0
3RD 0 0
~ 0 0
at t e In ormation proYI ed is true an t at I declare that no legal impediment exists
22. SIGNATURE OF BRIDE. 6\1 ~ 8, ~~
I USE CURR~
23. SUBSCRIBED AND SWORN TO BEFORE ME. 11/18/2002
SIGNATURE OF TOWN OR CITY CLERK. DATE .
This license authorizes the, marriage in 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 for the urpose of a second or subs uent ceremony.
~ 24. TOWN OR CITY CL~RK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Glo , a
TIME MONTH
SEAL SIGNATURE DATE 11/18/2002
'-.,-I M~lr~ i&ush nger Falls, NY 12590 10:43 AM 11
S I WN A PM
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE A 0 0 RELIGIOUS
DATE AND AT THE TIME AND I
PIJ\CE INDICATED. I J... 02,... 9 0 OTHER, SPECIFY
;:freFJAJc$E: TITLEf&?~ 7ieOAJ;:r"8r~1fr.1ll1
'(!Ja/' DATE !4r', ~qJ ~.2.,
ttltllPlN~ fi:14,S tl.l(. J.2S'9o
couNrRutchess
CITYfTOWt:lwapplnger
DISTRIC:r1 ~68
NUMBER
REGISTER180
NUMBER
1. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSElI1 0-40-5026
D. SOCIAL SECURITY NUMBER '1
2. RESIDENCE ANew York B. Dutchess
(STATE) vL (COUNTY)
C. CHECK ONE 0 CITY Lj TOWN 0 VILLAGE
~~CIFY PoughkeepSie
D. STREET ADDRESS~U ~utton park t<oaCJ ZIP 1 i!6U3
.;
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO
3. A. AG~5 3B. DATE OF BIRTH 09 /'12 /'1947
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Semi - Retired
B. TYPE OF IND~TRY OR BUSINES~
5. PLACE OF BIRTJ:.oughkeeps.e, New York
. (CITY, STATEICOUNTRY IF NOT USA)
6. FATHER
A. NAME Helmuth Michels
B. COUNTRY OF BIRTH Holland
7. MOTHER
A. MAIDEN NAME Mary Walsh
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE J
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~RCE CIVIL ATULMENT
vi'
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT lID 0 DEATH
C. DATE IJ\ST MARRIAGE ENDED? 08 /24 /1918
MON1;ljt 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 PIJ\CE ISSUED AGAINST WHOM
(MONTH, DAY, YEARL (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 04/14/1972 ~oughkeepsie, New York rj'
2ND 08124/1918 poughkeepsie, New York
DtfTH
21. SIGNATURE OF GROOM.
3RD
4TH
I, being duly swom, depose a S
as to my right to enter into the m .
29. OFFICIANT
NAME (PRINT)
SIGNATURE.
DOH.98 (11I9B)
,
I
"I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL V)
!Jill
/~.~-{J~
L 0 SUPPLEMENTAL FILE
--3
FROM THE BRIDE
Maria S. Kilpatrick
FIRST MIDDLE CURRENT SURNAME
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Piedra
c. SURNAME AFTER MARRIAGE Michels
(OPTIONAL - SEE REVERSE053-56-1161
D. SOCIAL SECURITY NUMBER .
12. RESIDENCE ~ew York B. Dutchess
(STATE) wi. (COUNTY)
C. CHECK ONE 0 CITY l,.J TOWN 0 VILLAGE
~~CIFYPougtiKeepSle
D. STREET ADDRES?U ~utton f-ISI1C t<oau
11. A. FULL NAME
13. A. AGE58
12
13.B. DATE OF BIRTH
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATIONSe1f - Employed
B. TYPE OF IND'tliTRY Of!. BUSINE~ Ketall
15. PLACE OF BIR~arcelona., :spa.n
(CITY, STATEICOUNTRY IF NOT USA)
16. FATHER
A. NAMELuis Piedra
B. COUNTRY OF BIRT~paln
17. MOTHER
A. MAIDEN NAME Maria Grado
B. COUNTRY OF BIRT~pain
lB. NUMBER OF THIS MARRIAGE J
Dl1TH
YEAR
1 it CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY f4,rr.f/V:.~'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY 1tJu@!fKI!I:PSflZ
STATE
NAME (PRINT)
SIGNATURE.