150
23. SUBSCFUBED AND SWORN TO BEFORE ME
SIGNAT\JRE;i CITY CLERK ~ DATE
This Iictnseauthorizes<tI'I~ marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Re@tioris Law ~11 to perforlfi marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
~ ., ' 0/ If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
z,,~ 24 TOWN OR CITY CLE.RK 25. A. SOLEMNIZATION PERIOD BEGINS
W . . ยท '. ~ NAME (PRINT) Glona J. Morse
~ 'JS.E~L f~;;;'""'~ ' om 0911812002 ""' MO"H "'" MOO'"
/ ~~~':~~~llush Rd, Wap in er Falls, NY 12590 03:27~~ 09 19 200 11 17 2002
. .,{ T . . CITYITOWN STATE ZIP
I C~IFY THAT I SOU:,MHl2ED' . SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF TbN! o'PER. .
SONS'NAjoIED ABOVE'ON THE IME MO. DAY YEAR 00 RELIGIOUS
DATE AND l'J!iE TIME;. ~D AM
PLACE INDICA\f"\l " ',;' PM 9 0 OTHER, SPECIFY
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STATE-OFNEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Wayne Theiss
MIDDLE CURRENT SURNAME
T
COUNTY Dutchess
CITY/TOWN Wappinoer
~~~~~CRT 1368
~~~~J~R 150
1. A FULL NAME
FIRST
0-
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 116 44 0424
D SOCIAL SECURITY NUMBER --
2. RESIDENCE A. NY B. Dutchess
c. CHECK ONE (STAg) CITY ~ TOWN 0 VILLAGE (COUNTY)
AND W .
SPECIFY applnger
D. STREET ADDRESS 2386 Route 9 D ZIP 12537
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
01 / 10 / 1
MONTH DAY YEAR
3. A. AGE 46
38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Correction Officer
8. TYPE OF INDUSTRY OR BUSINESS N Y S Corrections
5. PLACE OF BIRTH Yonkers, New Yark
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Matthew Theiss
8. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME MarQaret Lau
e. 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
B. HOW DID LAST MARRIAGE END? (3) ri DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C DATE LAST MARRIAGE ENDED? 09 / 17 / 2002
MONTf1I 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
09/17/2002 pouohkeeosie, New York r"f
DEATH
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21. SIGNATURE OF GROOM ~
29. OFFICIANT
NAME (PRINT)
TITLE
SIGNATURE ~
MAILING ADDRESS
STREET
30 WITNESS TO CEREMONY
CITY/TOWN
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
DATE
I
::; I A I t: t'ILI: NUMEu::::n
(THIS SPACE FOR STATE USE ONL Y)
/ sf-.
Ii 1.1..1-, .
~5?t., / Not lLS~J)
"<97'-
L 0 SUPPLEMENTAL FILE
~
1,. A. FULL NAME
FROM THE BRIDE
Lori C. Brown
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Theiss
(OPTIONAL. SEE REVERSE) 127-68-9370
D SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B Dutchess
(STATE).J (COUNTY)
C. CHECK ONE 0 CITY Ll TOWN 0 VILLAGE
D :~:~~~A::~~~e~oute 9 D ZIP 12537
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
03 /24 /1972
YEAR
13. A. AGE 30
13.8. DATE OF BIRTH
MONTH
DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Food Service
B. TYPE OF INDUSTRY OR BUSINESS Dairy Mart
15 PLACE OF BIRTH Port Chester, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Robert Brown
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Jud'l Ha'ldel1
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
8. HOW DID LAST MARRIAGE END? (3) r!f DIVORCE (3) 0 ANNULMENT <J61 DEATH
C. DATE LAST MARRIAGE ENDED? 05 / 21 / 2 2
MONTtV 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
0512112002 poughkeepsie, New York 0" 0
o 0
o 0
o 0
legal impediment exists
DEATH
o
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~
