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104 "- N >- I- Z > w if) w <( '" C g ::> 0 I if) Z 0 ~ <( 0: >- if) t5 . W 0: W CJ <( 0' 0:. <( L lL 0 W >- <( 0 u: ~ 0: W 0 w 0: w ffi I >: <Il if) ::> if) ::> w z 0: 0 0 Z 0 " <( >- >- w W lL 0: 0 >- W UJ "- if) w en z w () .J 2:i:z ~~~ W <( o:"'N I-ffiZ if)-.JL ::>ow ~,-,5 >-Zif) Z- ~~b ttaU) 0>->- W~C5 ~Z"' O~ Z:::::i~ 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 ~