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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Donald M. Kintz
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVOI3fE CIVIL ANN/j-MENT
01
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE1 0 (3) 0 A~'tMENT q)~TH
C. DATE LAST MARRIAGE ENDED? Y /
MONTH ., DAY
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
(M9~~Di'Y,~~). L(C'TY, STATElCQUNTRYtlF N~ USA) SEL~POUSE
lU/.jll ~~ uzerne Lloun y, t"'a 0 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
f my knowledge belief that the information I provided is
Dutchess
r (KiNTY
J vvapplnger
CITYfTOWN
DISTRICT 1 jtjtj
NUMBER
REGISTER 1 jj
NUMBER
1. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 141-/8-4124
D. SOCIAL SECUaJ,.TY NuMBER
2 RESIDENCE A t-'ennsylvanra B. Luzerne
(STATE)" (COUNTY)
C. CHECK ONE D 0 CITY 0 TOWN 0 VILLAGE
AND uryea
SPECIFY 729 Main Steet
D. STREET ADDRESS
15042
ZIP
.,
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED V'b~E? :7 YES 0 f~
3. A. AGE 32 3B. DATE OF BIRTH / 1 / if
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION H V A C Installer .
Ralston Mechanical
B. TYPE OF INDUS;qlYQ~ BI,lSIN'BS I\J J
5. PLACE OF BIRTH t"'erm Am oy, ew ersey
(CITY, STATE/COUNTRY IF NOT USA)
t-
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6. FATHER
A. NAME Theodore Kintz
USA
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME Evelyn Pugh
USA
B. COUNTRY OF BIRTH 2
8. NUMBER OF THIS MARRIAGE
DEAcr
YEAR
21.
w
CJ)
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I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
.~
r I~ IO~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Cheryl A. Foehrenbach
~
11. A. FULLNAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF rerA~T
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) U94-54-0360
D. SOCIAL SEC4BJTY NUMBER,
t"'ennsYlvanra LUzerne
12. RESIDENCE A. . B.
(STATE)" (COUNTY)
C. CHECK ONE.-.. _ Q CITY 0 TOWN 0 VILLAGE
AND uu, yt::a
SPECIFY 729 Mi:li/l SlIt::d
D. STREET ADDRESS
18642
.I
E. IS RESI~~E WITHIN LIMITS OF CITY OR INCORPORATED ~~GE? 19 YES 99'f4
AGE 13.B. DATE OF BIRTH / /
MONTH DAY YEAR
ZIP
13. A.
14. EMPLOYMENT
Accountant
A. USUAL OCCUPATION , . I EJ I e
rv t::/Ili t:: t::vt:: u~" 1t::IIL UI ~.
B. TYPE OF INDUSJ:ijYaliil.US~~$' hi . . k
t"'o ~nKee/Jsle ew T ur
15. PLACE OF BIRTH '
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME
Carl Foehrenbach
USA
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
Helen Steller
UtjA
1
B. COUNTRY OF BIRTH
1B. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV<(fCE CIVIL AN"tl-MENT
DEA(Y
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNUUMENT
/ /
(2) 0 DEATH
YEAR
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
22. SIGNATURE OF BRIDE
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TYPE OF CEREMONY
o ~ELlGIOUS
10 OTHER, SPECIFY
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURR~ ~
A. STATE NEW YORK B. COUNT; ~ L
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
fJ ;'Y' ...
SPECIFY IOka.Hk~~p"l
TITLE
DATE
)\.C. ?~
o,/f l( (0"
STAT
31.
NAME (PRINT)
SIGNATURE ~