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Dutchess
COUNTY W 0
app" Igt:r
CITYiTO~1ol68
DISTRICTI,)
~~~1~~~r20
NUMBER
::i I A I t:. Ur- Nt:. VV Y Ut'U\..
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GBOOM
Joel N: Fnedenberg
~
(THIS SPACE FOR STATE USE ONL Y)
.,y /In ~."I
4t!lA 1 3- leI. . t '"
v
L 0 SUPPLEMENTAL FILE
1 A. FULL NAME
FROMR~ri3~!l(~8hY
~~8hy
B BIRTH NAME (MAIDEN NAME)'Fft~tffiflberg
C SURNAME AFTER MARRIAGE "91 ~nGon A
(OPTIONAL - SEE REVERSE,.. - U- ~
D SOCIAL S~~'W~rk Dutcl.ess
12 RESIDENCE A. (STATE) ...'" B. (COUNTY)
C ~H6CK WappiflgeT" 0 TOWN 0 VILLAGE
SPECIFY 1 Blake Dm.'(;
D. STREET ADDRESS
,,'"
11 A FULL NAME
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
"-
N
BIRTH NAME. IF DIFFERENT
C s~~~~~ciN~~E~~:~~e~~sEl)16-40-24 16
D SOCIAL SE~~\'l'Bfk Dutchess
2 RESIDENCE A ..; B. (COUNTY)
VILLAGE
(STATEI
C ~H6CK o\ivappm~er 0 TOWN 0
SPECIFY 18 lakt:: Dtive
D STREET ADDRESS
12590
ZIP
~
E IS R~NCE WITHiN LIMITS OF CITY OR INCORPORATEij'~LAGE? flg 0 YES ~'t
3 A AGE 3B DATE OF BIRTH L /
MONTH DAY YEAR
E IS RE~~NCE WITHIN LIMITS OF CITY OR INCORPORAT"11ILLAGE? 01 0 YifCI!i.g'O
13 A. AGE 13.8. DATE OF BIRTH L L
MONTH DAY YEAR
14. EMPLOYMENT Physical Therapist Assistant
A USUAL OCCUPATION Taconic Do Do S. O.
8. TYPE OF IND'f~tW~~, New York
15. PLACE OF BIRTH
(CITY, ST A TE/COUNTRY IF NOT USA)
16 FATHER Thomas J. Leahy
A. NAME USA
8. COUNTRY OF BIRTH
4. EMPLOYMENT
Social Worker
A. USUAL OCCUPATION TaGulliG D. Do S. O.
B. TYPE OF IND~TRY Q!l.IW.SI~.s. . . ..
crOOK.YII I~ew Tor"
5. PLACE OF BIRTH '
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER H F . d b
erman ne en erg
A. NAME USA
B COUNTRY OF BIRTH
7 MOTHER
17 MOTHER Audrey Percent
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH 2
18. NUMBER OF THIS MARRIAGE
19 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI>(ORCE CIVIL A/ftULMENT
"
DEftTH
Miriam Kessler
A. MAIDEN NAME
USA
B COUNTRY OF BIRTH 4
8 NUMBER OF THIS MARRIAGE
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~RCE CIVIL A~ULMENT
D1jTH
-
B HOW DID LAST MARRIAGE END? (3) 0 DIVOFlf2 (3) ~NULMENT 1 ~~ DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVO'f2 (3) l2~NULMENT199lf DEATH
C DATE LAST MARRIAGE ENDED? .~ / / C. DATE LAST MARRIAGE ENDED? . / /
MONnl' DAY YEAR MONT'" DA Y YEAR
o ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
1ST ff/f3r191fPar:kefSGufg~Wesr~~fQlnia S~F SPOUSE ~~rf9~R13d~REffiATf(f~ijftfdff(OT USA) SELF SPO~E
03/13/1980 Poughkeepsie, New York ~ 0 1ST ' 0 0
2ND '12106/1999 Poughkeepsie, New York ~ 0 2ND 0 0
3RD 0 0 3RD 0 0
o 0 4TH 0 0
knowledge and belief that the information I provided is true and at I declare that no legal impediment exists
,
21. SIGNATURE OF GROOM ~
2. SIGNATURE OF BRIDE ~
02
23 SUBSCRIBED AND SWORN TO B RE ME
SIGNATURE OF TOWN OR CITY RK ~ DATE
This license authorizes th arriage in New York Stat of person authorized
Relations Law ~11 to perform marriage ceremonies within W 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 CeiI8'r'ili{ J. Morse 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
r-^-.
{ SEAL }
'-v-'
YEAR
TIME
MONTH
ZIP
03:01 ~~ 03
STATE
27. TYPE OF CEREMONY
CITY TOWN
26. SOLEMNIZATION OCCURRED
TIME MO DAY YEAR 0$ RELIGIOUS
.::J'_~ ~~ r.!) ~~ Jl)\i\....- 9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
28 PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF WTOWN OF D
iJJk~(( S
10 CIVIL
29 OFFICIANT':;)- 1.. fie (. r' ~T~,(,
NAME (PRINT) n() I}f(,.". c. r ~ - ,. --.,
~~~ .CA'
SIGNATURE ~ \\.c-. ):1..,<..,\..."-...... - --\....~
MAILING ADDRESS '. c-
\ ~ CO \ ff\J. ~ I \.,.tt lJ:.)t+E.-UY\ KJ~--.J
STREET CITY'TOWN
30. WITNESS TO CEREMONY
-
NAME (PRINT) c.' mf]
SIGNATURE~...2 ?It,
DOH-98 (11/98)
TITLE '\1t.(sb~ +c.\.('<::l..J M 'AlI k
DATE :)- '}.. (J- 1.... Q \l L
C~1'lNCt,l-..'h 0 to') 'ill
STATE
SPECIFY
L~G'1Q c{[L
o
VILLAGE OF
31
NAME (PRINT)
SIGNATURE ~