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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~CRT 1 368 .
~5~~~~R60
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Eric Paul Kedzielawa
MIDDLE CURRENT SURNAME
~I"IC r"1L.C numDcn
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kimberly April Callen
MIDDLE CURRENT SURNAME
.-J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 89
D SOCIAL SECURITY NUMBER 102-62-0 6
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWlII"tJ VILLAGE
~~~CIFY Wappingers Falls
D STREET ADDRESS 98 Carmine Dr. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? '6 YES 0 NO
3. A. AGE30 3B. DATE OF BIRTH 03 /26 /1979
MONTH DAY YEAR
04
13. A. AGE29
3B. DATE OF BIRTH
MONTH
4, EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Fishkill Plains
5. PLACE OF BIRTHPoughkeeDsie. Ny
(CITY, STATE / COUNTRY IF NOT USA)
6, FATHER
A. NAME John Matthew Kedzielawa
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Frances Linda Mierzwa
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14, EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESsBerea Elementary
15. PLACE OF BIRTHBronx, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMERobert Callen
'B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAME Ann Chieco
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o . 0
DaTH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,'.~ YEAR
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
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
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
and belief that the information I provided is true and that I declare that no legal impediment exists
dJiaJ lQp -'
USE C@ NAME '/'l
DATE 06/30/2009
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that ~ best 0 my
as to my right to enter into th~ s: ~
21. SIGNATURE OF GROOM~
USE CUR
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 If checked, this license is to be used only for the purpose of a second or subsequent ceremony,
~ 24, TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) John C. Masterson
TIME YEAR
SEAL SIGNATURE ~ DATE
I..- -..J MAI.l.Iel.G.A~I)flE;$S AM 07 01 2009
-v- LU IVllam 12:48 PM
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
by New York Domestic
MONTH
YEAR
08
29 2009
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY D ~ t"ha.s
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
SPECIFY 'P()f)ff It k ~"f s " e.
NAME (PRINT)
SIGNATURE.