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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
David M B~f1lch
MIDDLE CURRENT SURNAME
COUNTY 1J1Itchess
CITY/TOWN Wf'lppinger
~~~~~crJ 1 :1RR
~5~1~~~R ?7
A FULL NAME
FIRST
8 BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER
111-54-9034
B QMtypess
[] VILLAGE
2 RESIDENCE A N(~'ME~ nrl<
C CHECK ONE [] CITY WTOWN
AND
SPECIFY W8rringF'r
D STREET ADDRESS 7 A Pemhroke Circle ZIP 1 ?fi90
IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? [] YES cY' NO
MONt1 / DQa / YEW6
3 A
AGE 33
38 DATE OF BIRTH
4 EMPLOYMENT
A USUAL OCCUPATION Tp:::lr:hpr
B TYPE OF INDUSTRY OR BUSINESS Cf'lrmel Centri'll School
s. PLACE OF BIRTH New York NPiN Y nrk
(CITY, STATE,COU~TAY IF NOT USA)
6 FATHER
A. NAME S~my R~r1Ir:h
B COUNTRY OF BIRTH Irf'lq
7, MOTHER
A MAIDEN NAME Eleanor Rosenthal
B COUNTRY OF BiRTH II S A
8 NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) [] DEATH
o
o
B HOW DID LAST MARRIAGE END? (3) [J DiVORCE
C DATE LAST MARRIAGE ENDED?
(3) [] ANNULMENT
/ /
MONTH DAY YEAR
o ARE ANY FORMER SPOUSE(S) ALIVE? [] YES :::J 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 STA TE USE ONL Y)
I
()MI
,/ '7' ,)
"J. . t 1
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Aimee N Beckwittl
MIDDLE CURRENT SURNAME
~
11 A, FULL NAME
FIRST
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Baruch
(OPTIONAL - SEE REVERSE)
SOCIAL SECURITY NUMBER 058-74-9656
12 RESIDENCE A N~~EYork B. qMt~e~s
C CHECK ONE [] CITY []o,IrOWN 0 VILLAGE
AND \^' .
SPECIFY V 'I:::l rrlrloer
o STREET ADDRESS 7 A Pemhroke Circle ZIP 1 ?fi!=10
E is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES CY NO
13 A, AGE 22 13,8 DATE OF BIRTH MOOO / ~~ /WA~g
14, EMPLOYMENT
A. USUAL OCCUPATION Stlldent
B TYPE OF INDUSTRY OR BUSiNESS SI my Pllrr:h:=lsP
15. PLACE OF BIRTH ~t~~r'';WitOt.i;>~IFY&?~~AI
16. FATHER
A NAME P~III Bedo,Nith
B COUNTRY OF BIRTH II S A
17 MOTHER
A. MAIDEN NAME Sandra Alebcio
B COUNTRY OF BIRTH I f S A
18, NUMBER OF THIS MARRIAGE 1
19, PREVIOUS MARRiAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) :::J DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C, DATE LAST MARRIAGE ENDED? / /
MONTH DA Y YEAR
o ARE ANY FORMER SPOUSE(S) ALIVE? [J 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
o 0 18T 0 ,-
o 0 2ND 0 r:::
o 0 3RD 0 [J
o 0 4TH 0 '
y knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
22 SIGNATURE OF BRIDE ~ (i;..~ ~iJw~
USE CURRENT NAME
23 ~~~fT~~~DO~~~~~O~: Zt~yBg~~~~E DATE O:1/?fi/?nm
This license authorizes the marriage in New York any person authorized by New York Domestic
Relations Law 911 to perform marriage ceremonies W in 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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
21 SIGNATURE OF GROOM ~
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{ SEAL }
'-v-'
NAME (PRINT)
TIME
MONTH
YEAR
MONTH
YEAR
09:3ftM
PM
03
26
200
05
24 2002
liP
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DA TE AND AT THE TIME AND
PLACE INDICATED
STATE
27 TYPE OF CEREMONY
o ~RELlGIOUS
9 0 OTHER, SPECIFY
1:J CIVIL
:~\( 1Utc';,
29. OFFICIANT
NAME (PRINT)
28, PLACE WHERE MARRIAGE OCCURRED
A STATE NEW YORK B. COUNTY
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF [g TOWN OF 0 VILLAGE OF
SPECIFY \t~ Mil ,,.J (,-t!.~ F /.H...-i..-S
?-)t:>
ZIP
WITNESS TO CEREMONY
J-r;/~/(( ~
SIGNATURE ~