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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael L Bock
23 SUBSCRIBED AND SWORN TO BEFO ME
SIGNATURE OF TOWN OR CITY CL RK ~
This license authorizes the marriage in New York Sta
Relations Law S11 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 only for the purpose of a second or subsequent ceremony.
,,-I"-., 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)Gloria
TIME YEAR
SEAL SIGNATURE ~ DATJl8/09/2002
'-v-' ~'~taar~B'ush Rd afls NY 12590 1 :38 AM
STREET STATE ZIP PM
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND ~ 10 AlII q ., O? 90 OTHER, SPECIFY
PLACE INDICATED -; PM I K.-/ . .4
29. OFFICIANT 0N <J.G.IJ -7 s: .r f!?A. J eFE"" ,-:::.
NAME (PRINT). ""-". r J 'I,v _~'-
SIGNATURE ~ 4 ";jttJ#1t.f .~-::;Z;1I;1/11 ",~.o ./
MAILlNG)9DRE~ /J /U"
Ii rrG~GI2v'NIZ n- v''t<!/'f'/f\!"&:.J=;(!S
STREET CITYITOWN
30. WITNESS TO CEREMONY
/!JICI-I1l EL
COUNT..Qutchess
CITYITOw~appinqer
~~~~~R1368
~G~I~J~R127
A. FULL NAME
MIDDLE
CURRENT SURNAME
FIRST
CL
N
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERS'"'94-32 2895
o SDCIAL SECURITY NUMBER U -
2 RESIDENCE ANew York B Dutchess
(ST A TEl ~ (COUNTY)
C CHECK ONE 0 CITY"" 0 TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D STREET ADDREss1 03 A Jackman Drive ZIP 12603
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YE~O NO
.44 A 942
DAY YEAR
3 A AGSO
02
MONTH
38. DATE OF BIRTH
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4 EMPLOYMENT
A. USUAL OCCUPATIO~nemployed
B. TYPE OF INDUSTRY OR BUSINESS
5 PLACE OF BIRTINew York New York
. (CITY, STATE/C/:'UNTRY IF NOT USA)
6. FATHER
A NAMELester Bock
B. COUNTRY OF BIRT~ S A
7. MOTHER
A MAIDEN NAME Nora Culbert
8. COUNTRY OF BIRTHU S A
8 NUMBER OF THIS MARRIAG~
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
wi
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C DATE LAST MARRIAGE ENDED? 06 /29 /1992
MO~ 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
13T06/29/1992 Poughkeepsie, New York "'D
DEATH
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2ND
3RD
21. SIGNATURE OF GROOM ~
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STATE FilE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
illite
1 ~ il3 . t' ~
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Norma L ChaDdelaine
~
11 A FULL NAME
CURRENT SURNAME
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENHansen
c. SURNAME AFTER MARRIAGEBock
(OPTIONAL. SEE REVERS1ilo63-40-6223
D. SOCIAL SECURITY NUMBER U
12 RESIDENCE MA BHamDden
(S~TEI (COtrNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~~cl~estfield
D. STREET ADDREsZ3 Georae Street ZIP1085
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ....0 YES 0 NO
26 11(47
YEAR
13 A. AG55
04-
MONTH
DAY
13.8. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATIOr!Jnemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTiYonkers New York
(CITY. STAT~/COUNTRY IF NOT USA)
16. FATHER
A. NAMidohn Kovach
B. COUNTRY OF BIR1\) S A
17. MOTHER
A MAIDEN NAMdVlarion Pedll77i
B COUNTRY OF BIRM S A
18. NUMBER OF THIS MARRIAGE 3
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
1
(3) 0 ANNULMENT (2)'6 DEATH
/2000
YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED? 04 /19
MONJ,II DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? LJ 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
1sr!l?,25/1~88 c;.ity Of Springfield, '"6
o
o
2ND
3RD
o
o
by New York Domestic
MONTH
YEAR
2002 10
08 2002
28. PLACE WHERE MARRIAGE OCCURRED
1 ~ CIVIL
A. STATE NEW YORK 8. COUNTY Dv rcti,:; S$
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF "f! TOWN OF 0 VILLAGE OF
SPECIFY Po llt9-rf ){tEEP!:" IIZ.
ZIP
31 WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~