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COUNTY Dutchess
CITYfTOWN WappinQer
~~~~~c; 1368
~5~I~J~R 104
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Oliver Spiecker
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
tJittt
t(-/13C;f
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Brenda M. Smith
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
BIRTH NAME, IF DIFFERENT
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Spiecker
(OPTIONAL' SEE REVERSE) 1 04 62 8500
D. SDCIAL SECURITY NUMBER --
12. RESIDENCE A. N Y 8. Dutchess
(STATE).-J (COUNTY)
C. CHECK ONE 0 CITY LI TOWN 0 VILLAGE
~~~CIFY Wappinger
D STREET ADDRESS 6 Circle Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r1 NO
13. A. AGE 28 13.B DATE OF BIRTH 10 / 12 /1973
MONTH DAY YEAR
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 096 72 5039
o SOCIAL SECURITY NUMBER --
2 RESIDENCE A New Yark 8 OranQe
(STATE).J (COUNTY)
C CHECK ONE 0 CITY LJ TOWN 0 VILLAGE
~~~CIFY NewburQh
D STREET ADDRESS 1 Ambassador Lane
ZIP 12550
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
01 / 28 / 197
MONTH DAY YEAR
3 A AGE 26
38 DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Nail Technician
B TYPE OF INDUSTRY OR BUSINESS Self-employed
15 PLACE OF BIRTH Camp Lejeune, North Carolina
(CITY. STATE/COUNTRY IF NOT USA)
4. EMPLOYMENT
A. USUAL OCCUPATION Graphics Illustrator
B TYPE OF INDUSTRY OR BUSINESS Spherion
5 PLACE OF BIRTH New York, New York
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A NAME Brian Smith
B COUNTRY OF BIRTH USA
17. MOTHER
A MAIDEN NAME Barbara Lastrom
B COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
6. FATHER
A. NAME Peter Spiecker
B COUNTRY OF BIRTH Germany
7. MOTHER
A. MAIDEN NAME Petra Willrath
B. COUNTRY OF BIRTH Germany
8 NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES .
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH 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
MONTH 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
15T 0 0 15T
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I, being duly sworn, depose and say, that to the best of my k'tpwledge and belief that the information I provided is true ~ that I declare that no
as to my right to enter into the marri~e.1atli.' I .
21. SIGNATURE OF GROOM ~ . ~ 22. SIGNATURE OF BRIDE ~ ~,'j
SE CURRENT NAM ..
o
o
o
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Stat of the bride and groom named above by any person authorized
Relations Law ~11 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 CLEflK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) GlOri J.
{ ~ ~ ~
SEAL SIGNATURE ~ / ,"
~ MA~tflOO'(fdf~bush Rd, 02:02~~ 07 16 200
STREET STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
TE
by New York Domestic
MONTH
YEAR
09
13 2002
o 0 REliGIOUS
9 0 OTHER, SPECIFY
11iil CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTyDu1('\.-w
29 OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY ~C>~~~Q(j~\Q..,
NAME (PRINT)
SIGNATURE ~
