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COUNTY Dutchess
CITYITOWN Wappinger
~~~~~CRT 1368 .
~5~~J~R 79
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
J;JjpiE'1 S~lit~RRENT SURNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Amher Ni~nle Knrn
MIDDLE CURRENT SURNAME
~
1. A FULL NAME
11. A. FULL NAME
FIRST
FIRST
ll.
;:;
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NXTATE)
C. CHECK ONE 0 CITY 0 TOWN olZI
~~~CIFY W;:Jppingers F;:JlIs
D. STREET ADDRESS 58 Market St
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 26 3B. DATE OF BIRTH nt; /
Mo~R
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 090-76-6914
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN W!'I VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 58 Market St ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
13. A. AGE ?? 3B. DATE OF BIRTH 04 /19 A987
MONTH DAY YEAR
B. Q~j~e!=:!=:
VILLAGE
ZIP 12590
f!i'l
1Q
DAY
YES 0 NO
/ 1983
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION ~tl uiFmt
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH Rehnvnt Israel
(CITY, STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Office Staff
B. TYPE OF I~DUSTRY OR BUSINESS Elant at Fishkill
15. PLACE OF BIRTH Rhinebeck. Ny
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Isre::ll ~::Ilit::ln
B. COUNTRY OF BIRTH Lithuania
7. MOTHER
A. MAIDEN NAME Shera Taiz
B. COUNTRY OF BIRTH Lithuania
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
16. FATHER
A. NAME Michael F Pek
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Michelle Ann Korn
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
~
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
w
en
z
w
o
:::;
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 D3RD
4TH 0 0 4TH
I duly swear/affirm. depose and say, that to the best of my knowledge and belief that the information I provided is true an
as to my right to enter into the mamage sta e.
21. SIGNATURE OF GROOM ~ ,^_.'\ 22. SIGNATURE OF BRIDE ~
SE CUR AME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State 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 " checked. this license is to be used only for the urpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
o
o
o
DATE
07/27/2009
by New York Domestic
r-^-..
{SEAL}
~
NAME (PRINT)
MONTH
YEAR
MONTH
YEAR
TIME
SIGNATURE ~
MAILING ADDR
20 Mi 01
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
AM
01 :06PM
2009
09
25 2009
07
28
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF VVILLA
29. OFFICIANT
NAME (PRINT)
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) 2"' ! e.ey, C. LA.> h~ 'QJr
SIGNATURE~ r' ~_~\).,)~~
NAME (PRINT)
SIGNATURE~