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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GRQOM
James E. Gescheidle
Dutchess
COUNTY W .
applnger
CITY/TOIllNJ68
DISTRICT'I.J
~~~I~~~R44
NUMBER
1 A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
a.
N
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)117 -72-8350
D SOCIAL SE~~~Ulf6~ Uutcness
2. RESIDENCE A. (STATE)..! 8. (COUNTY)
C. CHECK ONf.. .ca lOlLY 0 TOWN 0 VILLAGE
AND vvapplnyer
SPECIFY 40 I Chelsea Cay
D STREET ADDRESS
f2590
.;
E IS RE~'liNCE WITHiN LIMITS OF CITY OR INCORPORATEDO~GE? /.]20 YES .Q....f5
3. A. AGE 3B. DATE OF BIRTH ~ ~
MONTH DAY YEAR
ZIP
4. EMPLOYMENT
Field Technician
A. USUAL OCCUPATION \1 rtz:
ve on
B. TYPE OF IND~TRY OR !UJ~INES~, ..c-..
5. PLACE OF BIRTHljrOrlX, New TOII\
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER J G h "dl
ames esc el e
A. NAME
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Janet Mula
B. COUNTRY OF BIRTH U ~ A
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVifCE CIVIL A~ULMENT
DljTH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(21 0 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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
.Uftt
.6 -It, ' tj(
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Lauren Dunn
-.J
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), I~IFFER~T "'1
bescnelu e
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)125-72-73 76
D SOCIAL S~~~l~AEr\ uutcness
12 RESIDENCE A. B.
(STATE) .,.
C. CHECK ctli. uJ;!JY 0 TOWN 0 VILLAGE
AND vvappsnyer
SPECIFY 40 I Chelsea Ca
D. STREET ADDRESS Y
(COUNTY)
...
Y)87.(O
YEAR
E. IS RE:trCE WITHIN LIMITS OF CITY OR INCORPORATE~ 'ttLAGE?)I' 0 0
13. A. AGE 13.B. DATE OF BIRTH _
MONTH DAY
14. EMPLOYMENT G h' D .
rap IC eSlgn
A. USUAL OCCUPATION 5 b. t T h I
unuurs ec no 091
B. TYPE OF IND~TRY OfiUlUSINESS. "" v..c-..
15. PLACE OF BIRTHfJougnKeepsle, new 1011\
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER J 0
A. NAME ames unn
B. COUNTRY OF BIRTHU S A
1~ MOTHER .
A. MAIDEN NAME Maureen H8V1can
8. COUNTRY OF BIRTHU S ~
lB. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
Di)ORCE CIVIL A~ULMENT
Dl1TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(31 0 ANNULMENT
/ /
(21 0 DEATH
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
ffi
CD
::;
::J
Z
o
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Vl
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that
as to my right to enter into the marriage
21. SIGNATURE OF GROOM"
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
ledge and belief that the information I provided is tru
o 0
D D
o 0
o 0
al impediment exists
23. SUBSCRIBED AND SWORN TO BE ORE ME
SIGNATURE OF TOWN OR CITY CLERK"
This license authorizes the marriage in New York S te of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies with 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 C~ CLERKJ 25 A SOLEMNIZATION PERIOD BEGINS
!blOna . .
NAME (PRINT)
w
en
z
w
u
::::i
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{ SEAL }
'-y-I
22. SIGNATURE OF BRIDE"
OATE
by New York Domestic
TIME
MONTH
YEAR
SIGNATURE ..
Mm'MfiMfebush
.1 04/26/2002
DATE
all ,NY 12590
AM 04
03:14 PM
TITLE C A, f-I c) l.. , ' C
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
26. SOLEMNIZATION
TIME MO.
3~ OS 1/ 02-
29 OFFICIANT J 0 JE:..R ~ 1/. W I LS{I A I
NAME (PRINT) f". I t::. I V
SIGNATURE" ,/~r tp/L .
MAILING ADDRE~
/(..<-'3 . JA(p:so,v 51 fr\H 1:../ '- ~
STREET CITY/TOWN
30. WITNESS TO CEREMONY
9 0 OTHER. SPECIFY
DATE
NY
. STATE
NAME (PRINT)
SIGNATURE ..
DOH-9B (11/98)
v
ZIP
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY D/"I-fc.hL>' ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF )8l TOWN OF 0 VILLAGE OF
SPECIFY F; s rI 1<./ L- L.
31.
NAME (PRINT) .
L/
SIGNATURE ..
"...