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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Matthew D Simon
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYiTOWN Wappinger
~~~~kCRT 1368
~5~I~J~R 45
A FUll NAME
FIRST
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N
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) c 07 65.....4
o SOCIAL SECURITY NUMBER ~J91- - L
2 RESIDENCE A N Y B Dutchess
(STATE) (COUNTY)
C CHECK ONE D CITY cYTOWN D VILLAGE
AND .
SPECIFY Wappinger
D STREET ADDRESS 510 Maloney Road H 14 ZIP 12603
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? DYES ['f' NO
3 A AGE 31 36 DATE OF BIRTH 01 / 1q / 1q7
MONTH DA Y YEAR
4 EMPLOYMENT
A. USUAL OCCUPATION Psychologist
B TYPE OF INDUSTRY OR BUSINESS St Francis Hospital
5. PLACE OF BIRTH Lana Island New York
(CITY, ~ATE/COUNTAY IF NOT USA)
6. FATHER
A. NAME Barry Simon
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME .lllrlith M;:!i~lp~
B COUNTRY OF BIRTH l1 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
B. HOW DID lAST MARRIAGE END? (3) D DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
I
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
I
.aMt
t
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Cheryl A Schanck
MIDDLE CURRENT SURNAME
~
11. A FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Simon
(OPTIONAL. SEE REVERSE) 063 72 3057
o SOCIAL SECURITY NUMBER --
12 RESIDENCE A. N Y B. Dutchess
(STATE) (COUNTY)
C CHECK ONE D CITY c::i""'rOWN D VilLAGE
AND W .
SPECIFY applnger
o STREET ADDRESS 510 Malonev Road H 14 ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE? DYES c:t" NO
13 A. AGE '/4 13.6 DATE OF BIRTH O!) /~? /~977
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Counselor
B. TYPE OF INDUSTRY OR BUSINESS Dutchess Comm. Colleae
15. PLACE OF BIRTH Yonkers. New York
(CITY. STATE'COUNTRY IF NOT USA)
16 FATHER
A. NAME Herbert W. Schanck
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME .Janice M Holdner
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
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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 D D D D
2ND D D D D
3RD D D D D
D D
o legal impediment exists---
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law S11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D 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
21 SIGNATURE OF GROOM ~
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{ SEAL }
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NAME (PRINT
---
DATE
by New York Domestic
TIME
MONTH
SIGNATURE ~
MAILING ADDf1Ei1S
20 Miaalebus
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
DATE 04/29/200
ppin~er Falls, NY 12590
CITY.'" WN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TI E MO DAY YEAR 0 ~L1GIOUS
9 D OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
DOH.98 (11/98)
09:04\M
PM
04
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTfJ(jMts.>
c
VILLAGE OF
