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COUNT..,Qutchess
CITYrrOw~appinQer
~~~~~CR-' 368
~~~I~J~135
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Eric H. Schwark
MIDDLE CURRENT SURNAME
I
STATE FlU:. NUM~C"
(THIS SPACE FOR STATE USE ONLY)
914ll
'7.;3.(1)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Dana M. Hvnson
MIDDLE ~ CURRENT SURNAME
~
11. A. FULL NAME
FIRST
A FULL NAME
FIRST
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Schwark
(OPTIONAL - SEE REVERSEn95-60-7665
o SOCIAL SECURITY NUMBER U
12 RESIDENCE New York BDutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY 'tJ TOWN 0 VILLAGE
~~~cIFWaDDinaer
o STREET ADORES~ 5 F Surrey lane
ZIP12590
o YES"D NO
1!.i77
YEAR
CL
N
B BIRTH NAME. IF DIFFERENT
3 A. AG~6
04
MONTH
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A AG~4 13.B DATE OF BIRTH 07 11'1
MONTH DAY
3B. DATE OF BIRTH
14. EMPLOYMENT
A USUAL OCCUPATlmSocial Worker
B TYPE OF INDUSTRY OR BUSINEsDutchess ARC
15. PLACE OF BIRTtli~~Y~h~~~Rrl?~ USAI
16. FATHER
A NAMElton Hynson
B COUNTRY OF BIRTW S A
17 MOTHER
A. MAIDEN NAMEKsthryn HIII~p.
B COUNTRY OF BIRTI.J S A
lB. NUMBER OF THIS MARRIAGE 1
19 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINES::Carmel Central School
5 PLACE OF BIRTPouahkeeDsie,'New York
(CITY': STATE/COuNTRY IF NOT USA)
6 FATHER
A. NAMESlephen Schwark
B. COUNTRY OF BIRTJl S A
7. MOTHER
A. MAIDEN NAME pHmp.Is Hp.ming.w1\Y
B COUNTRY OF BIRTHU S A
8 NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH OA Y YEAR
o 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
MONTH DAY YEAR
o 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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to the best of m
as to my right to enter into the marri tate. /
21 SIGNATURE OF GROOM ~
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York S
Relations Law !}11 to perform marriage ceremonies with
o If checked, this license is
~ 24 TOWN OR CITY CLERK
{ } NAME (PRINT)Gloria
SEAL SIGNATURE ~
~ 'bl~iJai~ ush Rd
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
o 1 ST [J C
o ~D 0 0
o 3RD 0 0
o 4TH 0 0
d belief that the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ :1A-rr.A. '1Y1 al1-1 ...11 ~~
us~ c\:.AREljr ---- -
DATE 06/20/2002
te of the bride and groom named above by any person authorized by New York Domestic
New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o be used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
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YEAR
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TIME
YEAR MONTH
DATEc06/20/2002
F ails NY 12590
Y OWN STATE ZIP
27. TYPE OF CEREMONY
YEAR 0 [{].,..fl!(IGIOUS 1 0 CIVIL
tJ 2.. 9 0 OTHER, SPECIFY
2002 08
19 2002
28 PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY nt., \.J.J"~;
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~AGE OF
SPECIFY \.tJ(~f',(): v,J 0 "'C; \- 0.,,\\ ~
29 OFFICIANT
NAME (PRINT)
TITLE
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~