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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Wallace G Benewav, III
MIDDLE CURReNT SURNAME
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'
as to my right to enter into the marriage state.
&00,,-,,-
23 ~~~2T~~~DO~NT~~Ot~ ~~yBg~~~E ~
This license authorizes the marriage in New York and groom named above by any person authorized by New York Domestic
Relations Law 911 to perform marriage ceremonies wi 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
} NAME (PRINT) GIO,r,ia J. Morse /) ""'- A
{ ~ . 7 ~/7~ TIME MONTH
SEAL SIGNATURE ~ '~/" / 1/ t9~;;"TE 12/03/200
'-v-I MAIL~8~'CfaTebush Rd, ~.Qin06r Falls, NY 12590 12:4;~ 12
STREET CITY/TOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
~~~SM~:~~g~B~V:H~N PTEH~ TIME MO OAY YEAR 0 ()( RELIGIOUS
~~~E ~~g,t:T:~E TIME ANO 3 (2.5 A iZ.. z3 6 \ 9 0 OTHER, SPECIFY
COUNTY Dutchess
CITY.TOWN Wappinger
1368
153
DISTRICT
NUMBER
REGISTER
NUMBER
1 A FULL NAME
FIRST
<:
BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 089-66-7691
o SOCIAL SECURITY NUMBER --- -- ----
2 RESIDENCE A New York B Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY 0 TOWN D""VILLAGE
~~~CIFY Wappingers Falls
D STREET ADDRESS 32 stuart Avenue
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3 A AGE :1? 38 DATE OF BIRTH 10 /
MONTH
ZIP 12590
D"'YES 0 NO
OR / 1 ~R
DAY YEAR
4. EMPLOYMENT
A USUAL OCCUPATION Computer Salesman
B. TYPE OF INDUSTRY OR BUSINESS Self - Employed
5 PLACE OF BIRTH Pouahkeeosie. New York
ICITY, SFATE/COUNTRY IF NOT USA)
6 FATHER
A. NAME Wallace Beneway Jr
B. COUNTRY OF BIRTH USA
7 MOTHER
A MAIDEN NAME Patricia Funk
B, COUNTRY OF BIRTH USA
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) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(31 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULEO. PROVIOE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
21 SIGNATURE OF GROOM ~
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~~St~~'i;;iliT ~~. ~~_L~. ~7~
SIGNATURE ~ lSu- v __ _t~
MAILING ADDRESS
3d .... {'Y\ ~~
STREET
30, WITNESS TO C
TITLE
DATE
,...y
STATE
NAME (PRINT)
SIGNATURE ~
DOH.98 (11/98)
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
"I
?/.!!1it
/ - CO "(/1
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Maranda D Niederkorn
MIDDLE CURRENT SURNAME
.-J
11. A FULL NAME
FIRST
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Reneway
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 333-60-7022
12 RESIDENCE A. New Yark B Dutchess
1ST A TEl (COUNTY)
C CHECK ONE 0 CITY 0 TOWN 0 ~ILLAGE
~~~CIFY Wappingers Falls
D STREET ADDRESS 32 stuart Avenue
ZIP 12590
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE' [J'IYES 0 NO
01 / OR /197~
MONTH DAY YEAR
13 A. AGE ?R
13.B DATE OF BIRTH
14. EMPLOYMENT
A USUAL OCCUPATION Developmental Aide
B. TYPE OF INDUSTRY OR BUSINESS New York State
15. PLACE OF BIRTH Mount Vernon. Illinois
(CITY. STATE.'COUNTRY IF NOT USA)
16. FATHER
A. NAME Ronald Niederkorn
8 COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Mary Ann Oennis
B COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW 010 LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) 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
o
o
LJ
22 SIGNATURE OF BRIDE
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B COUNTY DJ"'lC-~.J
vMtOt...
\ 2.- - .z....? -0 \
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF C( VILLAGE OF
SPECIFY I'Y\.'Lui2-<l~(
\L~--<-t~-
ZIP
31 WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~