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COUNTY Dutchess
CITY/TOWN Wappinger
1368
6
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Charlp-~ A Nnrman
MIDDLE CURRENT SURNAME
FIRST
I
5T A TE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
DISTRICT
NUMBER
REGISTER
NUMBER
P: e./( -lle
11
J-l~'lljj
L D SUPPLEMENTAL FILE
FROM THE BRIDE
.Ip-::ln M Hp~~lpr
MIDDLE CURRENT SURNAME
~
A FULL NAME
11. A FULL NAME
FIRST
8 BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) ??O_C?_71 "'1
o SOCIAL SECURITY NUMBER ___ ~_ ~ _!:L
2 RESIDENCE A. N Y B. nlltr.hp~~
,STATE) (COUNTY)
C CHECK ONE 0 CITY 0 TOWN cYVILLAGE
~~~CIFY Wappingers Falls
o STREET ADDRESS 1 Market Street ZIP 12590
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? [JoI'YES 0 NO
3 A. AGE 50 38. DATE OF BIRTH MONQl / DQ4 / YEk95
4. EMPLOYMENT
A USUAL OCCUPATION H::lir SfyJi~t
B TYPE OF INDUSTRY OR BUSINESS ()..vn BLJsinp-~~
5 PLACE OF BIRTH Raltimnrp- Marvland
(CITY, STATE;COUmRY IF Ncrf USA)
6 FATHER
A NAME Waltpr r'irpy
B COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME Virgie Mae Mkins
B COUNTRY OF BIRTH I J S A
B NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
B. BIRTH NAME (MAiDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Hessler
10PTIONAL . SEE REVERSE)
o SOCIAL SECURITY NUMBER 119-54-5156
12. RESIDENCE A. N V B 01 Jtr.hess
id A TE) iCO"N1'~!
C. CHECK ONE 0 CITY O",,"OWN 0 VILLAGE
AND
SPECIFY Hydp- Park
D STREET ADDRESS 10 3rd Drive ZIP 12538
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES cYNO
13 A. AGE 45 13.8. DATE OF BIRTH MOOO / G,,() / \g~6
14 EMPLOYMENT
A USUAL OCCUPATION Director Of Child Care
8. TYPE OF INDUSTRY OR BUSINESS Sf ~::lhrini
15 PLACE OF BIRTH Rrnny Npw Ynrk
ICITY, STA-n=!COUNTRY IF NOT USA)
16. FATHER
A. NAME Robert Hessler
8. COUNTRY OF BIRTH I J S A
17. MOTHER
A. MAIDEN NAME Mary Persico
B. COUNTRY OF BIRTH I I S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
n
(2) 0 DEATH
o
o
n
n
n
(2) 0 DEATH
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(3) 0 ANNULMENT
/ /
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
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) ICITY, 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 tr e
as to my right to ente ' rriage st
21 SIGNATURE OF
o
[J
o
22. SIGNATURE OF BRIDE ~
~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNA TURE 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 ~11 to perform marriage ceremonies within 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
DATE
by New York Domestic
~
{ SEAL}
'-.,-I
YEAR
MONTH
YEAR
TIME
MONTH
03
10 2002
01
10
200
STR ET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
2B PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY Ot]{!.it39
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~VILlAGE OF
SPECIFY uJApP//Y6~&/./:;
L)
ZIP
31. WITNESS TO CERE~NY
NAME (PRINT) r kl \ h~\ I?\ , ~ It ~T"^...; IL
SIGNATURE ~ ,k L\: \J.-V1\""V\ CL n- H) L