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~OUNTY
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NUMBER
REGISTER
NUMBER
Dutchess
Wappinger
1368
177
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMSER
(THIS SPACE FOR STATE USE ONLY)
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
1. A. FULL NAME
Jeffrey
FIRST
David
MIDDLE
VonH::l1Epn
CURRENT RNAME
11. A. FULL NAME
~~S~l1ihr MIDJIariaRn:a J~~~'AME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE VonHagen
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 086- 6 8- 7 2 n 1
12. RESIDENCEA. NptJ York B. nllUneS'i
(STATE) (CoUNTY)
o CITY ~ TOWN 0 VilLAGE
Wappinger
D. STREET ADDRESS 9 Brown Road
B BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 056- 5 L -1 .., 1 L
o SOCIAL SECURITY NUMBER ___ _9 - 2_ 9
2. RESIDENCEA. New York B. nl1f"rnpc:c:
,STATE) (COUNTY)
C. CHECK ONE C CITY IX TOWN 0 VilLAGE
AND W.
SPECIFY applnger
o STREET ADDRESS 9 Rrol'.JTI RO.<ln ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES!J NO
3. A AGE 42 3B. DATE OF BIRTH 1<'1" n / 09 /1 Q "8
MONTH DAY ~
C. CHECK ONE
AND
SPECIFY
12')90
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Xl NO
13. A. AGE . ?? 13.B. DATE OF BIRTH Feb. / 20 / 1 q78
MONTH DAY YEAR
14. EMPLOYMENT
4. EMPLOYMENT
A. USUAL OCCUPATION NRI Technologist
B. TYPE OF INDUSTRY OR BUSINESS TTnpmr' oyed
15. PLACE OF BIRTH ~l1ffprn.... New York
(CITY, STATEiCOUNTRY IF NOT USA)
16. FATHER
A. NAME Henry Pongpf"
B. COUNTRY OF BIRTH Cuba
17. MOTHER
UJ
....
<(
....
'"
A USUAL OCCUPATION Cabinet M.<lker
B. TYPE OF INDUSTRY OR BUSINESS Classic Woodworking
5. PLACE OF BIRTH YonkerR. NptJ York
ICITY, STATEiCOUNTRY IF NOT USA)
6. FATHER
A. NAME Carl Heinz VonHagen
B. COUNTRY OF BIRTH Germany
7. MOTHER
A. MAIDEN NAME
Frances Troiak
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Helen Marion PasReri
USA
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE F i r s t
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
8. NUMBER OF THIS MARRIAGE
First
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END?
13\ <= DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(31 C ANNULMENT
/ /
(2) 0 DEATH
YEAR
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES = NO
20. 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
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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) ICITY. STATE COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
o
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to
as to my right to enter into the marria
21. SIGNATURE OF GROOM.
o C 1ST
o 0 2ND
o C 3RD
o C 4TH
f my knowledge and belief that the information I provided i
22. SIGNATURE OF BRIDE
,C- Deputy
w
en
z
w
o
::i
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK.
This license authorizes the marriage in New rk State of the bride and groom named above by any person authorized
Relations Law 911 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 onl for the purpose of a second or subsequent ceremony.
24. TOWN OR C CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) ine H. Snowden, Town Clerk
SIGNATURE. DATE 9/21 /00
MAILING ADDRESS
PO Box 324. Wappingers Falls. NY 12590
STREtT CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED ' 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. AY YEAR 0 ~ RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
by New York Domestic
~
{ SEAL }
'-.t-I
TIME MONTH DAY YEAR MONTH DAY YEAR
AM
12: OOPM 09 22 00 11 20 00
28. PLACE WHERE MARRIAGE OCCURRED
CIVil STATE NEW YORK B COUNTY D\..fr"c.H e S.s
A.
10
3. 5 10 C57 ()()
".J.'i~'i.\::';; (j<~ V INg;.J~~fX>V
SIGNATURE . ~ .
MAILING ADDRESS .
1'500 ~ovre: "{;7Jo WAPF'rNGE"RS
STREET CITY!TOWN
30, WITNESS
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 'fi{ TOWN OF 0
TITLE ~l es.T
DATE SA'-. ex::.:r. It "2000
F',Io. L. L..S N'I I '2. ? Cl 0
STATE ZIP
31. WITNESS TO CEREMONY
VilLAGE OF
SPECIFY WAf'PIN 6E~
NAME (PRINT)
SIGNATURE.
NAME (PRINT)