136
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Daniel A. Pieters
I STATE FILE NUMBER I
(THIS SPACE FOR STA TE USE ONL Y)
..Jd f{- iJ. ~J.
Lo SUPPLEMENTAL FILE -1
]
Dutchess
COUNTY
Wappinger
CITYITO~~
DISTRICTI ",,68
~~~I~~~R136
NUMBER
FROM THE BRIDE
Kathleen L Stone
1. A. FULL NAME
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
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N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), ~DIFiERENT
C. SURNAME AFTER MARRIAGE Ie ers
(OPTIONAL. SEE REVERSEU95-6l:S-llll
D. SOCIAL S~~RITY N.!J~BEe
12. RESIDENCE ANew YOrK B. Dutchess
(STATE)'" (COUNTY)
C. CHECK CW 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY applnger
D. STREET ADDRESs609 Popula Boulevard
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSItJ:,;l-oi:S-l ;l;lU
D SOCIAL SEKjRITY N~Er\:
2. RESIDENCE A. ew 0 B. Dutchess
(STATE) ..I (COUNTY)
C. CHECK O~ JiL CITY f TOWN 0 VILLAGE
~~~CIFY appluger
609 Popula Boulevard
D. STREET ADDRESS
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ZIP 12590
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YEAR
ZIP ll:'9U
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YES Q NO
1816
YEAR
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E. IS R~I~NCE WITHiN LIMITS OF CITY OR INCORPORATE'bVtLAGE? 0
3. A. AG~ 3B. DATE OF BIRTH ~O
MONTH DAY
E. IS RE~6NCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGeA: 13.B. DATE OF BIRTH 02 ,,28
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATloNRegistered Nurse
B. TYPE OF IND~TRY OR BVSINE~I:i:stantora HOSpital
15. PLACE OF BIRT~ocnesler. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER .
A. NAMEMlchael Stone
B. COUNTRY OF BIRT~ :s A
4. EMPLOYMENT .
A. USUAL OCCUPATION Architect
5. :~:::;:I::~e~g~~~~~ ~:: patterson Assoc.
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER W p' t
A. NAME ayne Ie ers
B. COUNTRY OF BI RTH 1I S A
7. MOTHER
A. MAIDEN NAME Rose Rockwell
B. COUNTRY OF BIRTH U 52 A
B. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~RCE CIVIL ArfULMENT
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17. MOTHER
A. MAIDEN NAME Judy Covert
B. COUNTRY OF BIRT~ 5 A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DfiORCE CIVIL A'WULMENT
D(fTH
DlO'TH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVOrm (3) ~~NULMEN20tf.p DEATH
C. DATE LAST MARRIAGE ENDED? _~ / /
MON '"" 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
~W>/llll;l, ~)',,;{E;.AFl.\.. (Cj!Y, SIATElCQI.JNTRY,JF. NOIUSA) SELF SPO~E
1STUOIL4ULUU'1 r<ocnesler, New TOrK 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I, being duly sworn, depose an y knowledge and belief that the information I provided is t
as to my right to enter into the a
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END?
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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
YEAR
o 0
o 0
o 0
o 0
pediment exists
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21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
23. SUBSCRIBED AND SWORN TO B FORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York Stat of 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 purpose of a second or subsequent ceremony.
24. TOWN OR <c3(cftfR'J 25. A. SOLEMNIZATION PERIOD' BEGINS'
NAME (PRINT)
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25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
.~
{ SEAL }
'-v-I
TIME
MONTH
YEAR
MONTH
DAY
YEAR
AM 08
2:32 PM
28
2002 10
26 2002
STATE
27. TYPE OF CEREMONY
RELIGIOUS
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 41 /:J f~:Y
C. LOCATION OF CEREMONY /'
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY J 2 JZ,// S' ,4/8#1
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
1~IVIL
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29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
SIGNATURE ~ '
DOH.98 (11/98)