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056 + LO .,... ,.... (j) LO <Cw Z!;( <(Ii; I- Z o ~ ... ffic :> Ultll c( ltIE c ~~wu: oo"'u. mc:o~ c( 8.cf ~C")~ Ul__t: a 0 ~<( w.... ~O 0: C ~ .tij ::!i_ ... .... o Q) w.c 5 E !!; tll I-~ ~() w a: w ~ Ul Ul w a: o o -< ~ 13 w 0.. Ul STATE OF NEW YORK DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE FROM THE GROOM Mir.h::u:'!1 .In~eph Conrad MIDDLE CURRENT SURNAME COUNTYDutchess CITYfTOwNWappinger ~~~:~;1368 ' ~5~~l~R56 1. A. FULL NAME FIRST 0- N B. BIRTH NAME. IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL. SEE REVERSEJ..09 03 0178 D. SOCIAL SECURITY NUMBER !:J__ - __ - ____ 2. RESIDENCEA.Mnnt;:m::l B. Gallatin (STATE) (COUNTY) C. CHECK ONE ....0 CITY 0 TOWN 0 VILLAGE ~~~CIFY Bnzeman D. STREET ADDRESS 101 Grant Chamberlain Dr ZIP 59715 E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? ~ YES 0 NO 3. A. AGE24 3B. DATE OF BiRTH n~ /18 /1986 MONTH DAY YEAR I I 4. EMPLOYMENT A. USUAL OCCUPATION ~hldent B. TYPE OF INDUSTRY OR BUSINESS Montana State University 5. PLACE OF BIRTHWalnut Creek, Ca (CITY. STATE / COUNTRY IF NOT USA) 6. FATHER A. NAME Thnm;:!~ Che~ter Cnnrad B. COUNTRY OF BIRTH USA 7. MOTHER A. MAIDEN NAME Elizabeth Valentina Stuloff B. COUNTRY OF BIRTH USA B. NUMBER OF THIS MAR81AGE 1 9. PREVIOUS MARRIAGES ' A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT n 0 DEATH o B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE C. DATE LAST MARRIAGE ENDED? (3) 0 ANNULMENT / / (2) 0 DEATH STATE FILE NUMBER (THIS SPACE FOR STATE USE ONLY) L 0 SUPPLEMENTAL FILE FROM THE BRIDE Joanne Margaret Schepis MIDDLE CURRENT SURNAME .-J MONTH DAY YEAR D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO 10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION DATE OF DECREE PLACE ISSUED AGAINST WHOM (MONTH. DAY. YEAR) (CITYICOUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE 11. A, FULL NAME FIRST B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT C. SURNAME AFTER MARRIAGeGonrad (OPTIONAL. SEE REVERSEj 08-70-8417 D. SOCIAL SECURITY NUMBER 12. RESIDENCE Montana pallatin (ST.\TE) (COUNTY) C. CHECK ONE Y'o CITY 0 TOWN 0 VILLAGE ~~CI~ozeman D. STREETADDRESJ01 Grant Chamberlam Dr ZIp971b E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 11'0 YES 0 NO 71 }984 DAY YEAR 13. A. AG~6 04 3B. DATE OF BIRTH MONTH 14. EMPLOYMENT A. USUAL OCCUPATIO~chool Counselor B. TYPE OF INDUSTRY OR BUSINESSCounsehng 15. PLACE OF BIRT~oughkeepsie, Ny (CITY. STATE / COUNTRY IF NOT USA) 16. FATHER A. NAMeRominic Joseph Schepis . B. COUNTRY OF BIRT~ S A 17. MOTHER A. MAIDEN NAMEVeronica May Jones B. COUNTRY OF BIRTM S A lB. NUMBER OF THIS MARRIAGE 1 19. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT o 0 DOATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH / / ,'- YEAR C. DATE LAST MARRIAGE ENDED? MONTH DAY D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO ~ 20. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION DATE OF DECREE PLACE ISSUED AGAINST WHOM (MONTH. DAY. YEAR) (CITY/COUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE 1ST 2ND 3RD o 0 o 0 o 0 o 0 o legal impediment exists W tn Z -w o -::::i + ~~~ W ~~I= a:lI:~ ~ lii~~ (.) ::l(JW ~~g u: ~~~ ~ ~OUl w ~~~ (.) l!!~", o~z z::;_ 23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFO SIGNATURE OF TOWN OR CITY CLERK. This license authorizes the marriage in New York State 01 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 II checked, this license is to be used only lor the purpose 01 a second Dr subsequent ceremony. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS hn C. Masterson TITLE ])tU"D,J DATE5~ I~ I 1,;0 10 t,ij-K..urs/~ rJ~J.J YotZK STATE r-^-.. { } NAME (PRINT) SEAL SIGNATURE. MAILING ADDRESS '-v-' . STREET I CERTIFY THAT I SOLEMNIZED THE MARRIAGE OF THE PER. SONS NAMED ABOVE ON THE DATE AND AT THE TIME AND PLACE INDICATED. 29. OFFICIANT NAME (PRINT) NAME (PRINT) SIGNATURE. DATE by New York Domestic MONTH 25. B. SOLEMNIZATION PERIOD ENDS AT MIDNIGHT ON: YEAR MONTH DAY YEAR 05 27 2010 25 2010 07 10 CIVIL 2B. PLACE WHERE MARRIAGE OCCURRED A. STATE NEW YORK B. COUNTY ~t( ~ $.> C. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) o CITY OF ~ TOWN OF 0 VILLAGE OF SPECIFY fHt ~ ~K!.t (.>'It.. ~ ZIP 31. WITNESS TO CEREMONY NAME (PRINT) SIGNATURE. S ..8