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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ernest P. Doetsch
COUNTYDutchess
CITY frOWN VI/ appinger
~~J~~CRT1 ::.68
~G~I~J~R'155
1. A FULL NAME
CURRENT SURNAME
FIRST
MIDDLE
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE" 77 34-"'1"'00
D. SOCIAL SECURITY NUMBER '1 - Lt!..
2. RESIDENCE A. N Y B. Dutchess
(STATE) oJ... (COUNTY)
C. CHECK ONE 0 CITY'U TOWN 0 VILLAGE
~~~CIFY WapPin!?r
D STREET ADDRESS P. . Box 57
3. A. AGE59
ZIP 12590
""
YES 0 NO
/1943
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
03 /29
MONTH DAY
38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Painter
B. TYPE OF INDUSTRY OR BUSINESS Self-employed
5. PLACE OF BIRTHBaltimore, Maryland
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Ernest P. Doetsch, Jr.
B. COUNTRY OF BIRTH U S A
7. MOTHER
A. MAIDEN NAME Rose Boone
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 'tJ DIVORCE (3) 0 ANNULMENT (g) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 10 / 10 / 19!:1S
MONTijI 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 10/10/1995 Poughkeepsie, New York ~
I
"I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
~l1t /o.Jq ~ O~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Barbara A. Byer
-.J
11. A. FULL NAME
CURRENT SURNAME
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Casson
C. SURNAME AFTER MARRIAGE Doetsch
(OPTIONAL - SEE REVERSE)134-54-04 70
D. SOCIAL SECURITY NUMBER '"
12. RESIDENCE AN Y B. Dutchess
(STATE) "" (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 16 lJav/es Drive
ZIP 1 Z:J~U
.;
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO
/21 )959
DAY
13. A. AGE42
10
13.8. DATE OF BIRTH
YEAR
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Nurse
8. TYPE OF INDUSTRY OR BUSINESS t-lshk,1I Home Health
15. PLACE OF BIRTH Queens, Long Island, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Robert Casson
B. COUNTRY OF BIRTJJ S A
17. MOTHER
A. MAIDEN NAME Miidred Margarita
8. COUNTRY OF BIRTJ.J S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
o
o
o
.,;
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT ~ 0 OEATH
C. DATE LAST MARRIAGE ENDED? 09 / 01 /19 9
MONTiIV 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) SELF SPOUSE
1ST 09/01/1999 Poughkeepsie, New York 0 c5
~D 0 0
3RD 0 0
o 0
nd that I declare that no Ie al impediment exists
2ND
3RD
4TH
I, being duiy sworn, depose and
as to my right to enter into the ma
21. SIGNATURE OF GROOM
w
(J)
Z
W
()
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~
{ } NAME (PRINT
SEAL SIGNAT;; ~
'-v-I M~'Mf(im~bus
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMEO ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law 911 to perform marriage ceremonies within New York State, THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CL~RK 25. A. SOLEMNIZATION PERIOD BEGINS
a
SIGNATURE ~ "
DOH-98 (11/98)
DATE
by New York Domestic
TIME
MONTH
YEAR
ZIP
02:33 ~~ 09
1~
28. PLACE WHERE MARRIAGE OCCURRED
A STATE NEW YORK B. COUNT~uTC~
C. LOCATION OF CEREMONY
(CHECK ONE AN~ECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY tAl 14-fOt?,~
NAME (PRINT)
SIGNATURE ~
.