024
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COUNTY Dutchess
CITYIfOWN Wappinger
~~J:~~1368 '
~~~~~R24
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
William Hentnik
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sonia Renate Shipp
MIDDLE CURRENT SURNAME
~
1, A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGEHentnik
(OPTIONAL - SEE REVERSl'{)73-42-1859
D. SOCIAL SECURITY NUMBER
12. RESIDENCE l.JY BDutchess
(STATE) L (COUNTY)
C. CHECK ~E. 0 CITY~U TOWN 0 VILLAGE
~~CIFYvvappmger
D. STREET ADOREs! ~ Alpine ur
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEb61_36_7119
D. SOCIAl SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITYoob TOWN 0 VILLAGE
AND W .
SPECIFY appmger
D. STREET ADDRESS 7 E Alpine Dr ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CIlY OR INCORPORATED VILLAGE? 0 YESll'''o NO
3. A. AGE61 3B. DATE OF BiRTH 04 /18 /1948
MONTH DAY YEAR
~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YSS ..hlgND
13. A. AGE60 3B. DATE OF BIRTH 07 )J8 ~
MONTH DAY YEAR
-12590
ZIP
4. EMPLOYMENT
~ ~ A. USUAL OCCUPATION Retired
N B. TYPE OF INDUSTRY OR BUSINESS
'r'" 5. PLACE OF BIRTH Bronx, Ny
(CITY. STATE I COUNTRY IF NOT USA)
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6. FATHER
S A. NAME Stanley Hentnik
cC B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Helen Ronski
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATIO~dmin
B. TYPE OF INDY{lTRY OR BUSINESslnsurance
15. PLACE OF BIRTH::;cunmorpe, E:ngland
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMEBernard Frederick Shipp
'B. COUNTRY OF BIRTl-f=ngland
17. MOTHER .
A. MAIDEN NAME Gertude Alma Bertha RaJthe
B. COUNTRY OF BIRTJ3ermany
j
18. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV1RCE CIVIL ANOULMENT DEaTH D~ORCE CIVIL A~ULMENT D10'TH
B. HOW DID LAST MARRIAGE END? (3) t1 DIVORCE (3) 0 ANNULMENT 2~ 100DEAJH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORfE (3) 0 ~NULMENT 19~~ DEATH
c. DATE LAST MARRIAGE ENDED? 02 / 01 / C. DATE LAST MARRIAGE ENDED? 1 /' /
MONTty DAY YEAR MONT\II' DAY, '. - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? C"I YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
~
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY. IF NOT USA) SELF SPOUSE (MONTHbDAY ~EAR) (ClTYlCqUNTY, STATElli.qUNTRY, IF NOT USA) SELF SPOUSE
1ST 02/01/2010 Rockland, New York 0 ~ 1ST 11/10/1 t196 Westcnester, NY 0 ~
2ND 0 0 2ND 12/Uts/1 ~tsU vvnlte t-'Iams, Ny 0 ~
3RD 0 0 3RD .~ 0 0
4TH 0 0 4TH I'/, ,// 0 0
I duly swe!lr/affirm, aep'ose and say, that to the befjst of my knowledge and belief that the information I provided is true and th~~ jlclare that-rio legal impediment exists
as to my nght to enter Into the amage state. ~-_.-
21. SIGNATURE OF GROOM~ . · 22. SIGNATURE OF BRIDE~ /-' ?" :/.o?
US CURR ME U RRENT NAME
23. SU8SCRIBED AND SWORN TO/AFFIRMED BEFORE ME 04/05/2010
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
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
n
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
'-..t-I MAI~~G ~p
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
MONTH
YEAR
TIME
MONTH
12:58:~ 04
04 2010
2010
06
06
CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~~
C. LOCATION OF CEREMONY
(CHECK ONE AND yECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY ~ slf=.,"L,L ~. y.
c. ~"'~,.~
(. ~
NAME (PRINT)
SIGNATURE~