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. ~UNTY
~frOWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF;;NEW'iVORK-F
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Daniel Vincent
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY}
~
Dutchess
Wappinger
1368
52
/6\ ,11\ dc)
L 0 SUPPLEMENTAL FILE
~
FROM THE BRIDE
Heather Lee
FIRST MIDDLE
Gelles
CURRENT SURNAME
,. A. FULL NAME
Ebner
CURRENT SURNAME
11. A. FULL tWoE
MIDDLE
FIRST
B. BIRlli NAME (MAIDEN NAME), IF DIFFERENT
C. SURtWoE AFTER MARRIAGE Ebne r
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 0 5 4 -6 4 -4 26 0
12. RESIDENCE.\. New York B Duo:hess
(STATE) . ,COUNTY)
o CITY 0 TOWN K1 VILLAGE
Wappingers Falls
D. STREET ADDRESS 1 Creekview Court
12590
"-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 594 -4 4 -4762
o SOCIAL SECURITY NUMBER
2. RESIDENCE A New York B. Dutchess
(STATE) (COUNTY)
[! CITY 0 TOWN ~ VilLAGE
Wappingers Falls
D. STREET ADDRESS 1 Creekview Court
ZIP
C. CHECK CfjE
AND
SPECIFY
C. CHECK ONE
AND
SPECIFY
12590
ZIP
E. IS RESIDENCE WITHiN UMrTS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE 29 3B. DATE OF BIRTH April / 16 /1971
MONTH DAY YEAR
27
13. A. AGE
MONTH
DAY
14. EMPLOYMENT
Administrator
4. EMPLOYMENT
A. USUAL OCCUPATION
B. TYPE OF INDUSTRY OR BUSINESS Vassar College
15. PLACE OF BIRTH Kin~ston" New York
(CITY, STATE/COUNT IF NOT USA)
A. USUAL OCCUPATION Scientist
B. TYPE OF INDUSTRY OR BUSINESS Boehringer Ingelhe~
5. PLACE OF BIRTH Kine of Prussia" Pennsvl vania "
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME John Ebner
B. COUNTRY OF BIRTH USA
7. MOTHER
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Joel Gelles
USA
Amber Passer
USA
First
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Lov'Elaine Clayton
USA
First
18. NUMBER OF THIS MARRIAGE
8. NUMBER OF THIS MARRIAGE
19. PREVIOUS lAARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END? 13) C DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID i.AST MARRIAGE END? (3) 0 DiVORCE 3) = ANNULMENT 121 = DEATH
C. DATE ~T MARRIAGE ENDED? / /
MONTH JAY YEAR
O. ARE ANY FORMER SPOUSEIS) ALIVE? = 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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? eYES 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
0 [!
0 r
[!
1"j
21. SIGNATURE OF GROOM Ill>
DATE May 4, 2000
by New York Domestic
w
en
z
w
o
:::::i
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK Ill>
This license authorizes the marriage in New York St e 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 rpose of a second or subs uent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) ~ne H. ~d~ Town Clerk
SEAL SIGNATUREIIl>--E-'QttllLJ G-YA f'"'~.lL DATE 5/4/00 TIME MONTH DAY YEAR
MAILING ADDRESS 8: 30 AM
'-t-I PO Box 324 Wa in ers Falls NY 12590 PM 5
E
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
7
3
00
25, B. SOLEMNIZA T10N PERIOll
ENOS AT MIONIGHT ON:
MONTH
DAY
YEAR
5
00
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW 'yORK B. COUNTY)'" 1c.~4!'.u
c. LOCATION OF CEREMONY
(CHECK 9NE AND SPECIFY)
)( CITY OF O. TOWN OF 0 VlUAGE OF
SPECIFY,P..",e;.}I.oIr"':,.e..
27. TYPE OF CEREMONY
o ll1 RELIGIOUS
9 0 OTHER, SPECIFY
1 ~ CIVil
T1TLE \t\ ", ... ~ s -k..
DATE 5' /1 1 ItJ~1:' '
1-J I / 2..f,./
STATE
NAME (PRlNTl
SIGNo\11JRE.