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~ 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...~