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COUNTY Dutchess
CITYrrOWN Wappinger
~~J~~c; 1 368
~5~1;;~R 26
~ I A II: ur I~I:VV Tun~
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Alexander David Kurylo
MIDDLE CURRENT SURNAME
(TH/S SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Dorene Hope Sukup
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) 1 09 76-2125
D. SOCIAL SECURITY NUMBER -
2 RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY tJ TOWN 0 VILLAGE
~~~CIFY WappinQer
D. STREET ADDRESS 335 Cedar Hill Rd. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
3. A AGE 23 3B. DATE OF BIRTH 1 0 / 11 / 1985
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Kurylo
(OPTIONAL - SEE REVERSE) 106-68-9045
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STATE) J. (COUNTY)
C. CHECK ONE 0 CITY r:J TOWN 0 VILLAGE
~~~CIFY Wap~inger
D STREET ADDRESS 35 Cedar HIli Rd.
ZIP 12590
DYES '6 NO
)1'984
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 24 3B. DATE OF BIRTH 07 ,AJ7
MONTH DAY
4. EMPLOYMENT
A USUAL OCCUPATION Technician
B. TYPE OF INDUSTRY OR BUSINESS Audio Video. Systems
5. PLACE OF BIRTH Mahattan, NY
(CITY. STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Educator
B. TYPE OF INDUSTRY OR BUSINESS Beczak Environmental
15. PLACE OF BIRTH Manhattan, NY
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Edward Martin Sukup
'B. COUNTRY OF BIRTH USA
17. MOTHER
A MAIDEN NAME Carol Lee Slimak
B. COUNTRY OF BIRTHU SA
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
6. FATHER
A. NAME Walter Kurvlo
B. COUNTRY OF BIRTH Germany
7. MOTHER
A MAIDEN NAME Tania Monica Gordon
B COUNTRY OF BIRTH Czech Republic
B. NUMBER OF THIS MARRIAGE 1
9. 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 (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
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
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) (CITY/COUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
w
(/)
Z
W
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1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and that 1 declare that no legal impediment exists
as to my right to enter into the marnag~ /-
21. SIGNATURE OF GROOM~ /~ 22. SIGNATURE OF BRIDE~
USE CU~ USE CURRENT NAM
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME /
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perlorm 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
~
{ SEAL }
"-.t-I
YEAR
YEAR
MONTH
NAME (PRINT)
TIME
MONTH
SIGNATURE ~
MAILING !-'tDR.
20 Mid
STREET
1 CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
AM
12:58PM
04
23
2009
06
21 2009
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY a/64f";
C. LOCATION OF CEREMONY /
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 'fi VILLAGE OF
SPECIFY W t:! O{Jt/. ltfztf s f II- 1/5
. II T"
10 CIVIL
29. OFFICIANT
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)