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COUNTY Dutchess
CITYfTOW}J Wappmger
DISTRICT 'I 368
NUMBER
REGISTER 11
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIt' ~c
FROM THE GROOM
Trajan Gjorgjioski
MIDDLE CURRENT SURNAML
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
~
L D SUPPLEMENTAL FILE
1. A, FULL NAME
FROM THE BRIDE
Lisette Sagginario
FIRST MIDDLE CURRENT SURNAME
B BIRTH NAME (MAIDEN NAME). IF DIFFERENT Lisette Gonzalez
c, SURNAME AFTER MARRIAGE Gjorgjioski
(OPTIONAL - SEE REVERSE)117 -7 4-2382
D SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STATE).L (COUNTY)
C, CHECK Ot'l~ . 0 CITY U TOWN 0 VILLAGE
~~~CIFY vvapplnger
b F vvlnthrop Court
D. STREET ADDRESS
11. A, FULL NAME
FIRST
0-
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL, SEE REVERSE)139_19_0023
D SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY B Dutchess
(STATE).L (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
AND W .
SPECIFY appmger
D STREET ADDRESS 6 I- Winthrop Court ZIP 1 Ltl~U
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
09 /22 /1985
DAY YEAR
-12590
ZIP .;
DYES jJ NO
;t~84
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 25 3B. DATE OF BIRTH 01 ~O
MONTH DAY
3. A. AGE 23
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Driver
B. TYPE OF INOUSTRY OR BUSINESS Transportation
5. PLACE OF BIRTH Ohrid, Republic Of Macedonia
(CITY, STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Bank Teller
I:jankmg
B. TYPE OF INDU~TRY OR BI,11jINESS
15. PLACE OF BIRTH tsronx, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A NAME Nelson Gonzalez
'B. COUNTRY OF BIRTHPuerto RICO
17. MOTHER
A. MAIDEN NAME Audrey Ester Sanchez
B. COUNTRY OF BIRTHPuerto RICO
L
16. NUMBER OF THIS MARRIAGE
6. FATHER
A. NAME Boris Gjorgjioski
B. COUNTRY OF BIRTH Republic of Macedonia
7. MOTHER
A. MAIDEN NAME Anica Petreska
B. COUNTRY OF BIRTH Republic of Macedonia
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI10RCE CIVIL AN~ULMENT DE6TH
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT 0269 DEATH
C. DATE LAST MARRIAGE ENDED? 04 / 26 / 2
MONTfV 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) ICITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0 1ST 04/26/2007 Suffolk, County Ny r1
o 0 2ND
o 0 3RD
o 0 4TH
knowledge and belief that the information I provided is true a; d that
DEATH
o
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
YEAR
MONTH OA Y
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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to the b
as to my right to enter into the marnage state.
21. SIGNATURE OF GROOM~
o
o 0
o 0
o 0
d,eclare that no legal impediment exists
/
,a::;t- ,,' ~-2:C NATU,RE OF BRID
A E .
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en
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_ USECU E
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 by New York Domestic
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 MONTH YEAR MONTH
SEAL SIGNATURE ~ . . 03/12/2009
'-v-I MAI~~Gr\RPJ8f~' NY 12590 09:34AM 03 13 2009 05 11 2009
STREET ZIP PM
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICA T
YEAR
CIVIL
28, PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYQ TC.~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF ~ILLAGE OFir ~ II.
SPECIFY W A--PP/lVh E. tt...S 'i-tf'U:1
SIGNATURE~ .
DOH-98 (03/2006)
NAME (PRINT)
SIGNATURE~ ~