124
1. A. FULL NAME
STATE OF,. NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Cornelius Klaus
FIRST MIDDLE
COUNTY Dutchess
-X:lD:YfTOWN WappinRer
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Bremer
CURRENT SURNAME
11. A. FULL NAME
r-
STATE FILE NUMBER
(THIS SPACE FOR STATE USE 0Nt.Y)
071-46-0665
C. CHECK ONE
AND
SPECIFY
3. A. AGE
34
AUR.
MONTH
14. EMPLOYMENT
,/ "1\,,\00
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Carolyn Brenda
FIRST MIDDLE
~
Lewis
CURRENT SURNAME
3B. DATE OF BIRTH
13. A. AGE
Bremer
095-68-0308
33
May
MONTH
13.B. DATE OF BIRTH
A. USUAL OCCUPATION Correction Officer
B. TYPE OF INDUSTRY OR BUSINESS Downstate
5. PLACE OF BIRTH RidRewood, New Jersey
(CITY. STATE/COUNTRY IF NOT USA)
A. USUAL OCCUPATION UPS Loader
B. TYPE OF INDUSTRY OR BUSINESS Uni ted Parcel Service
15. PLACE OF BIRTH Yonkers , New York
(CITY. STATE/COUNTRY IF NOT USA)
4. EMPLOYMENT
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Cornelius Edward Bremer
USA
Jean Ann McClain
USA
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Gerald Edward Lewis
USA
Susan Margaret
USA
First
Buckley
Second
18. NUMBER OF THIS MARRIAGE
DEATH
DEATH
19. PREVIOUS MARRIAGES .
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES C 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
21. SIGNATURE OF GROOM ~
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DATE
NY
7/31/00
12590
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
One
B. HOW DID LAST MARRIAGE END? (3) IX DIVORCE (3) 0 ANNULMENT (21 C DEATH
C. DATE LAST MARRIAGE ENDED? June / 27 / 1996
MONTt\. DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ 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
6/27/96 Franklin County. Ohio ID
o
o
1ST
2ND
3RD
B. HOW DID LAST MARRIAGE END? (31 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
13) C ANNULMENT
/ /
21 C DEAi'-'
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22. SIGNATURE OF BRIDE
"
Deputy Town
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York S te of 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 If checked. this license is to be used onl for the rpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK Town Clerk 25. A. SOLEMNIZATION PERIOD BEGINS
Elaine H. Snowden,
NAME (PRI
C.
~ 1
TlTLE tD r'nLtn lLl wi I L Pn est
crllloo
,
A
27. ~ OF CEREMONY
o CIf RELIGIOUS
9 0 OTHER. SPECIFY
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME ANO
PLACE INDICATED.
26. SOLEMNIZATION OCCURRED
1M
Domestic
25. B. SOLEMNIZATION PERIOD
ENOS AT MIDNIGHT ON:
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
AM
1: 15 PM
8
1
00
9
2.9
00
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVil
A. STATE NEW YORK B. COUNTY f'xl+cA.i.j,j
lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF i:1'~OWN OF 0 VILLAGE OF
SPECIFY Gxf fiJJKll1
STATE ZIP
31. WITNESS TO CEREMONY tc$ ( IV . J.1 0'- ~ II 0
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