No preview available
032 + o en U? Nw ~S III >- Z ~ m m W a: Cl Cl < ~ u W Q. m w -(() Z -W o -:; + ~~z W 2-0 Iii~F to- a:",;5 < ~~~ 0 :lOW ~~g ~ ~~~ ~ item w ~~~ 0 l!!~", o~ Z::i1l: ~ I A II:: VI- NI::VV YVHI\ DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE FROM THE GROOM John Kozak. Iv MIDDLE CURRENT SURNAME COUNTY Dutchess CITYfTOWN WappinQer ~~J:~c~ 1 368 . ~~~~~~R 32 1. A. FULL NAME FIRST Q. N B. BIRTH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL - SEE REVERSE)068 74 3471 D. SOCIAL SECURITY NUMBER -- 2. RESIDENCE A. NY B. Dutchess (STATE) (COUNTY) C. CHECK ONE 0 CITYo!J TOWN 0 VILLAGE ~~~CIFY Wappinaer D. STREET ADDRESS 5 Wildwood Dr. ZIP 12590 E, IS RESIDENCE WITHIN LIMITS OF CIlY OR INCORPORATED VILLAGE? 0 YES tJ NO 05 /12 /1979 MONTH DAY YEAR 3. A, AGE 29 3B. DATE OF BIRTH 4. EMPLOYMENT A. USUAL OCCUPATION Water Dept. Village. of Wappinger B. TYPE OF INDUSTRY OR BUSINESS Municipality 5, PLACE OF BIRTH Poughkeepsie, New York (CIlY, STATE / COUNTRY IF NOT USA) 6. FATHER A. NAME John Kozak B. COUNTRY OF BIRTH USA 7. MOTHER A, MAIDEN NAME Anne Louise McQuillan 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 DEATH o B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE C. DATE LAST MARRIAGE ENDED? (3) 0 ANNULMENT / / (2) 0 DEATH 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) (CITVICOUNTV, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (THIS SPACE FOR STA TE USE ONL Y) L 0 SUPPLEMENTAL FILE FROM THE BRIDE Andrea Lynn Alfonso MIDDLE CURRENT SURNAME ~ 11. A. FULL NAME FIRST B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT C. SURNAME AFTER MARRIAGE Kozak (OPTIONAL - SEE REVERSE)1 07 -72-5026 D. SOCIAL SECURITY NUMBER 12. RESIDENCE ANY 8. Dutchess (STATE) (COUNTY) C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE ~~~CIFY Poughkeepsie D. STREET ADDRESS9 Church St. ZIP 12590 DYES '6 NO )1"978 YEAR E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 13. A. AGE 30 3B. DATE OF BIRTH 12 ~2 MONTH DAY 14. EMPLOYMENT A. USUAL OCCUPATION Retail ManaQer B. TYPE OF INDUSTRY OR BUSINESS Retail 15. PLACE OF BIRTH Phoenix, Arizona (CITY, STATE / COUNTRY IF NOT USA) 16. FATHER A. NAME Robert Alfonso . B. COUNTRY OF BIRTHU S A 17. MOTHER A. MAIDEN NAME Kim Hoolihan B. COUNTRY OF BIRTHU S A 18. NUMBER OF THIS MARRIAGE 1 19. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT o 0 DEATH o B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH / / . - YEAR 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 o 0 2ND 0 o 0 3RD 0 o 0 4TH 0 Y knowledge and belief that the information I provided is true and that I declare that no legal impedime 29. OFFICIANT Q ~V NAME (PRINT) . SIGNATURE. MAILING ADDRESS II eJ- '" STREET 30. WITNESS TO CER L..s 23. SUBSCRIBED AND SWORN TO/AFFIRM 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) TIME MONTH YEAR SEAL SIGNATURE. DATE 05/07/2009 "-v-I MAI20G MiRaers Falls NY 12590 11: 07 AM 05 ~ m ~ ~ I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY ~~~SM~~~~~~B~V;~N Pi.fE 0 $i RELIGIOUS DATE AND AT THE TIME AND PLACE INDICATED. 9 0 OTHER, SPECIFY STATE NAME (PRINT) DATE by New York Domestic MONTH YEAR 08 2009 07 06 2009 28. PLACE WHERE MARRIAGE OCCURRED 10 CIVIL A, STATE NEW YORK B. COUNTY I> 1JrtJ./ e .s s: VIC.Ai2. C. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) o CITY OF 0 TOWN OF Q!j VILLAGE OF SPECIFY W J!4 P (? I N G e Q ~ :r~ U...~