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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
R Y ~go&J1 i ~h :::lE'I R Ic~lit1T SURNAME
COUNTY nlJtchess
CITYrrOWN Wappinger
~~~:~~ 1 368
~~~I~~~R 61
1 . A. FULL NAME
FIRST
B. BIRTH NAME, IF OIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER ~04-0?-764~
2. RESIDENCE A. NY e, Dlltchp~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY..!'] TOWN 0 VilLAGE
AND
SPECIFY Hyrlp. P;::!rk
D. STREET ADDRESS 107 East Market St ; Apt 5BzIP 12538
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YESo(] NO
3. A AGE28 3B. DATE OF BIRTH MOQ.;L / '6l / ~E~R80
4. EMPLOYMENT
A. USUAL OCCUPATION HS Meith T p<3~hp.r
B, TYPE OF INDUSTRY OR BUSINESS Rp.n Hook CSD
5. PLACE OF BIRTH ~~~~!it~ 60~INTRY IF NOT USA)
6, FATHER
A, NAME GE'rard K1elIIS Rlltch
B. COUNTRY OF BIRTH l J S A
7. MOTHER
A. MAIDEN NAME M;::!ry Reth Wolfe
B. COUNTRY OF BIRTH l J S A
8. NUMBER OF THIS MARRIAGE 1
9. ~R~~~~IfRM6'FR~~A~TguSMARRIAGESWHtCHENDED 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 OA Y 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
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ni~rMc;1I~E M;::!rie KI J~~RENT SURNAME
~
11, A. FUll NAME
FIRST
B. BIRTH NAME (MAIOEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Rllt~h
(OPTIONAL - SEE REVERSE)1 09 70 9316
D. SOCIAL SECURITY NUMBER _ __ - __ - __ __
12. RESIDENCE ANY e.r1lltr.hess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~CIFY Hyde Park
D, STREET ADDRESS 107 East Market St.: Apt 5b ZIP 12538
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES -0 NO
13,A.AGE?7 3B.DATEOFBIRTH OFi AiR A~R1
MONTH OA Y YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Offir.e Assistant
B. TYPE OF INDUSTRY OR BUSINESS Financial
15. PLACE OF BIRTHPouahkeepsie, NY
(CITY, ~ATE / COUNTRY IF NOT USA)
16, FATHER
A. NAME~~ry .Io~erh Kujan
'B. COUNTRY OF BIRTJJ S A
17. MOTHER
A. MAIDEN NAME Diane Elizabeth Contelmo
B. COUNTRY OF BIRTt-U S A
18, NUMBER OF THIS MARRIAGE 1
19'~~~~~~{R~FR~~AE~Tgus 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 OA Y
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
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is t e
as to my right to enter into th arnage state,
21. SIGNATURE OF GROOM" ~ 1i\. 22. SIGNATURE OF BRIDE"
o 0
o 0
o 0
o 0
o legal impediment exists
USE CU
23. SUBSCRIBED AND SWORN TO/A FIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Y State of the bride and groom named above by any person authorized
Relations Law ~11to 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
~
{ SEAL }
'-v-'
NAME (PRINT)
ITY WN
26, SOLEMNIZATION OCCURRED
TIME O. DAY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
SIGNATURE~
K. BufJ,
K,,~
06/04/2008
by New York Domestic
TIME MONTH YEAR MONTH YEAR
AM 06 05 2008 08 03 2008
05:39PM
2B. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL STATE NEW YORK B couN~iA..((lCfSS
A.
,f. c f,e;l?ir
r;,1.x 7 /os
, (
I.;;.~ 0
ZIP
31. WITNESS TO CEREMONY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY ~:1ff';NGteS FAUS
SIGNATURE