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COUNTY
~iTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK I
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Richard Lee Steinbacher ,Jr. 11. A. FULL NAME
FIRST MIDDLE CURRENT SURNAME
CURRENT SURNAME
STATE ALE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
Dutchess
Wappinger
1368
174
/Jc)17/0~
L
-1
o SUPPLEMENTAL FILE
FROM THE BRIDE
Claudia T.
Schmitt
1. A FULL NAME
FIRST
MIDDLE
"-
N
B BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Steinbacher
(OPTIONAL - SEE REVERSE) 065 -6 0 -0 027
o SOCIAL SECURITY NUMBER
12. RESIOENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
AND W.
SPECIFY app1nger
o STREETADDRESS 34C Winthrop Court
12590
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER
2. RESIDENCE A. New Yo r k
,STATE)
D CITY ~ TOWN 0
Wappinger
34C Winthrop Court
C. CHECK ONE
AND
SPECIFY
139-64-1830
8. Dutchess
(COUNTY)
VILLAGE
ZIP 12590
ZIP
D. STREET ADDRESS
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
/01 /1970
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE' D YES ~ NO
13. A. AGE 27 13.B. DATE OF BIRTH March /22 / 973
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Registered Nurse
B.TYPEOFINDUSTRYORBUSINESS St. Francis Hospital
15. PLACE OF BIRTH Mt. Kisco, New York
(CITY, STATE/COUNTRY IF NOT USA)
3. A. AGE
30
May
MONTH
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Systems Operator
B. TYPE OF INDUSTRY OR BUSINESS Central Hudson
5. PLACE OF BIRTH Wilkes-Barre, Pennsylvania
ICITY, STATE/COUNTRY IF NOT USA)
6. FATHER
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
Harold Schmitt
USA
A. NAME Richard Lee Steinbacher, Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
JoAnn Talt
USA
1B. NUMBER OF THIS MARRIAGE Firs t
A. MAIDEN NAME
Lorraine Motovidlak
A. MAIDEN NAME
B COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE Firs t
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
B. COUNTRY OF BIRTH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
B HOW DID LAST MARRIAGE END? (3) :: DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D' ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END' 13) C DIVORCE
C. DATE LAST MARRIAGE ENDED?
,21 D DEATH
'3) c:: ANNULMENT
/ /
(2) [J DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? LJ YES :: NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY, STATEiCOUNTRY, IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? :: YES :: NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATEiCOUNTRY. IF NOT USA) SELF SPOUSE
1ST ~ 1ST
2ND 2ND
3RD ' 3RD
4TH 4TH
I, being duly sworn. depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare t
as to my right to enter into the marri ____::.::>
21. SIGNATURE OF GROOM ~
c
[J
D
CJ
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 York ate of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies wit in New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
LJ If checked, this license is to be used onl for the purpose of a second or subsequent ceremony.
-^- 24 TOWN OR LERK Town Clerk 25. A. SOLEMNIZATION PERIOD BEGINS
r- -..., ine H. Snowden,
{ } NAME (PRINT)
SEAL SIGNATURE ~ DATE 9/19/00
'-v-' M~'6N')fg~RE~ NY 12590 AM
STREET STATE ZIP 12: O()'M
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER- ~
SONS NAMED ABOVE ON THE OrRELIGIOUS
~t.r~E ~~glt:TJ~E TIME ANO 0 D 9 D OTHER. SPECIFY
11
18
00
DATE Sept. 19, 200C
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
9
20
00
1 D CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~-\ i-cL ~:S..
NAME (PRINT)
SIGNATURE ~
DOH-98 (1/98)
NAME (PRINT)
SIGNATURE ~
~OV~