079
..
COUNTY
CITVTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
Dutchess
Wappinger
1368
19
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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Benjamin L. Jeckel
MIDDLE CURRENT SURNAME
MtC
r .t1
t" ;J{/ . oV)
L C SUPPLEMENTAL FILE
FROM THE BRIDE
Suzette T. Vetter
~
I A. FUll NAME
11 A. FUll NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
12 RESIDENCE A
B BIRTH NAME (MAIDEN NAME) IF DIFFERENT
Jeckel
343-10-3692
New York B Dutchess
(STATE) oJI (COUNTY)
C CHECK ONE 0 CITY 0 TOWN"" 0 VillAGE
~~~CIFY Wappinger
19 f Pembroke Circle ZIP
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SDCIAl SECURITY NUMBER
"-
;:;
BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MAP,RIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER
2 RESIDENCE A New York B Dutchess
(STATE) J (COUNTY I
C CHECK ONE C CITY 0 TOWrr 0 VillAGE
~~~CIFY Wappinger
19 f Pembroke Circle ZIP
335-14-6010
D STREET ADDRESS
125 0
D STREET ADDRESS
12590
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VillAGE?
3 A AGE 23 3B DATE OF BIRTH )(2
DYES 0 NO
20
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE?
913. AGE 24 13.8 DATE OF BIRTH G1
MONTH
DYES 0 NO II'
m 1978
DAY YEAR
MONTH
DAY
YEAR
4 EMPLOYMENT
14 EMPLOYMENT
A. USUAL OCCUPATION Administrator Assistant
B TYPE OF INDUSTRY OR BUSINESS Pepsi
15 PLACE OF BIRTH Bloominaton. Illinois
(CITY, STATE/COUNTRY IF NOT USA)
A. USUAL OCCUPATION Financial Analyst
B TYPE OF INDUSTRY OR BUSINESS I. B. M.
5 PLACE OF BIRTH Chapel Hill. North Carolina
(CITY. STATE, COUNTRY IF NOT USAI
B COUNTRY OF BIRTH
Lawrence Jeckel
USA
16. FATHER
A. NAME
6 FATHER
A. NAME
B. COUNTRY OF BIRTH
Stanley Vetter
USA
7 MOTHER
A MAIDEN NAME
B COUNTRY OF BIRTH
8 NUMBER OF THIS MARRIAGE
Nancy Rankin
USA
1
17 MOTHER
A. MAIDEN NAME
B COUNTRY OF BIRTH
18. NUMBER OF THIS MARRIAGE
Suzanne Schleif
USA
1
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
19. 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
C DATE lAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) C DEATH
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
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES =:J 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
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 knowledge and belief that the information I provided is tru
as to my right to enter into the marri estate.
o D
o c
21 SIGNATURE OF GROOM ~
22 SIGNATURE OF BRIDE ~ '
o 0
C 0
iment exists
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York St e of and groom named above by any person authorized by New York Domestic
Relations Law S11 to perform marriage ceremonies withi 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.
24 TOWN OR CITY CLERK . 25. A. SOLEMNIZATION PERIOD BEGINS
GI na J. Mors
~
{ SEAL }
~
NAME (PRINT)
06/11/
NY 12590
ZIP
1~
YEAR
MONTH
YEAR
w
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Z
W
U
...J
w
~
<(
U
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t=
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08t2
PM
06
12
2002 OB
10 2002
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDIC~
28 PLACE WHERE MAP,RIAGE OCCURRED
A. STATE NEW YORK B COUNT'(9u;L/f?'fj
C lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) . .
o CITY OF. C TOWN OF _ ~~:~GE~~ J
.SPECIFY tc44fP;/l6$-1<f:5. ~.f2
U
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~