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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c~1368
~~~I:~~R 170
~ I #4. II:: ur I~C VV TUn"
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thomas Andrew Kopicki
MIDDLE CURRENT SURNAME
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
~
1 . A. FULL NAME
FROM THE BRIDE
Pamela May Purdy
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Harvey
c. SURNAME AFTER MARRIAGE Purdy-Kopicki
(OPTIONAL. SEE REVERSEI069_50_847 9
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(ST A TEI.L (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDREss52 Osborne HIli Road; Lot
11. A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSEJ090_50_5744
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0(] TOWN 0 VILLAGE
~~~CIFY WappinQer
D. STREET ADDRESS 52 Osborne Hill Road; Lot ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'6 NO
04 /09 /1956
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 50 3B DATE OF BIRTH 05 ~7
ZIP 12b90
o YES '6 NO
;1'958
YEAR
3. A. AGE 52
3B. DATE OF BIRTH
MONTH
DAY
MONTH
.-
:>
<C
4. EMPLOYMENT
A. USUAL OCCUPATION Maintenance Tech
B. TYPE OF INDUSTRY OR BUSINESS Apartment
5 PLACE OF BIRTH Port Chester, Ny
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Thomas Joseph Kopicki. Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Eleanor Anna Piscotty
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATION Lobster Boat Fisherman
B. TYPE OF INDUSTRY OR BUSINESS Fishing
15. PLACE OF BIRTH Brooklyn, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Jerry Lee Harvey
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Dorothy Tangen Thompson
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 2
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
OIVORCE CIVIL ANNULMENT
1 0
DEATH
o
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDEO BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 09 / 25 / 2007 '
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? &'YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20.
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 09/25/2007 PouQhkeepsie, Ny 0 ~ 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, depose and say,that to the b~t of my knowledge and belief that the information I provided is true and that I decl
as to my right to enter into t ate,
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF BRIDE~
USE CURRENT A
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York e of the bride and groom named above by any person authorized
Relations Law ~11to pertorm 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) Jo n C. Masterson
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE
I.- -J MAI~t)lG f>~IP~E:i AM 11
-v- LU IVl ual 01 :33PM
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME
PLACE INDICATED.
B. HOW DID LAST MARRIAGE END? (3) 6 DIVORCE (3) 0 ANNULMENT (210 DEATH
C. DATE LAST MARRIAGE ENDED? 01 / 05 / 19::10
MONT!U DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? LJ YES 0 NO
..
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
01/05/1990 Ulster County, Ny 0 ~
o 0
o 0
o 0
pediment exists
by New York Domestic
MONTH
YEAR
01
05 2009
07
2008
1[ll.~fv~:
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~ \l rt tf"~
C. LOCATION OF CEREMONY
(CHECK ONE ANDJPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY~\L.~~ ~4i.~; t.
()