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COUNTY
~ITOW"
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF;.:NEW,tYORK ;"r
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Arthur Daniel
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
Dutchess
Wappinger
1368
172
/~\\~vo ~0
L 0 SUPPLEMENTAL FILE
-.l
FIRST
CURRENT SURNAME
FROM THE BRIDE
11. A. FULLNAME Melissa Dawn
FIRST MIDDLE
Crites
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 234 17 8200
D. SOCIAL SECURITY NUMBER - -
12. RESIDENCE A West Virginia B Nicholas
(STATE) . (COUNTY)
o CITY Xi TOWN 0 VILLAGE
Sunnnersville
913 Main Street
W
tn
Z
W
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{ SEAL }
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DATE 9/15/00
NY 12590
1. A. FULL NAME
Erreich
Erreich
ZIP 26651
4. EMPLOYMENT
A. USUAL OCCUPATION Relief Child Care Worker
B. TYPE OF INDUSTRY OR BUSINESS Faltis Childrens'
5. PLACEOFBIRTH Bronx, New York
(CITY, STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES Xi NO
13. A. AGE 29 13.B.DATEOFBIRTH Oct. /05 /1970
MONTH DAY YEAR
A. USUAL OCCUPATION Child Care Worker
She! er B. TYPE OF INDUSTRY OR BUSINESS Faltis Childrens' Shelter
15. PLACE OF BIRTH Richwood, West Virginia
(CITY, STATE/COUNTRY IF NOT USA)
AM
1 : 00 PM
MIDDLE
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 094-66-6128
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. West Virginia B. Nicholas
(ST A TE);V (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Summersville
913 Main Street
C. CHECK ONE
AND
SPECIFY
D. STREET ADDRESS
Freeman Crites
USA
Goldie Foster
USA
First
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
26. SOLEMNIZATION OCCYRRED
1M A
AM
"'I;]O-PM
27. TYPE OF CEREMONY
o 1( REUGIOUS 1 0 CIVIL
9 0 OTHER, SPECIFY
3. A. AGE
29
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
29. OFFICIANT ---.t)' h I ~
NAME (PRINT) L t" ..- l'J.1' ~=-
SIGNATURE ~ ?'1-:~ t.-,
MAlUNG ADDRESS
1~f!i:).51 m 3]t';. W~J~r~ hils:
STREET IT
30. WITNESS TO CEREMONY
TITLE R~u. (C.l e."'5y)
DATE "\'A P f. J1;" ,1 oeiJ
t1/c? ItU'ln
STATE ZIP
31. WITNESS TO CEREMONY
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
Isadore Erreich
Poland
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
(3) 0 ANNULMENT
/ /
(2) = DEATH
C. DATE LAST MARRIAGE ENDED?
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
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) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
[J
o
22. SI(lNATURE OF BRIDE ~ RENT NAME
Deputy Town DAT~ept. 15, 2000
This license authorizes the marriage in New York St te 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 su uent ceremon .
24. TOWN OR CLERK Town Clerk 25. A. SOLEMNIZATION PERIOD BEGINS
ine H. Snowden,
Joy A. Rydberg
USA
B. NUMBER OF THIS MARRIAGE Firs t
A. MAIDEN NAME
B. COUNTRY OF BIRTH
18. NUMBER OF THIS MARRIAGE
~:tz
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t;~~ c(
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tIs~
W
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~~
1ST
2ND
3RD
4TH
I, being duly sworn, depose
as to my right to enter into t
o
o
o
[]
o
o
25. B. SOlEMNIZATlON PERIOD
ENOS AT MIDNIGHT ON:
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
9
16
00
11
14
00
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY D...f, h~H
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF IE VILLAGE OF
SPECIFY ~fJ'''5.~r''f h-JI-r