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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rnhprt Rri::m RIIY::lknw!=:ki
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYrrOWN Wappinger
~~~~~c; 1368
~G~I~~~R 50
1 . A. FULL NAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 085-62-9905
2 RESIDENCE A NY B. nlltr.hp!=:!=:
(STATE) (COUNTY)
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY arpmger
D STREET ADDRESS 20 Applesauce Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 34 38. DATE OF BIRTH 1? /?7 /1 q73
MON1H DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Civil Fnoinppr
B. TYPE OF INDUSTRY OR BUSINESS Engineering
5. PLACEOFBIRTHPnIJnhkeen!=:ie. NY
(CITY, ~ATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Fr~nk R Rllycknw!=:ki
B. COUNTRY OF BIRTH l J S A
7. MOTHER
A. MAIDEN NAME r.::lrnl Ann Garda
B. COUNTRY OF BIRTH l J S A
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
n
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMEr.rr
/ /
C. DATE LAST MARRIAGE ENDED?
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
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Alison Williams Stevens
MIDDLE CURRENT SURNAME
.-J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE RIJyakow!=;ki
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 116-60-7959
12 RESIDENCE A NY BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY otJ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESsZO Applesauce Lane
ZIP 12590
DYES '6 NO
/1'977
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE ::\n 3B. DATE OF BIRTH 06 ~9
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTH New Hartford. NY
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Halbert D Stevens
. B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Catherine J. Williams
B. COUNTRY OF BIRTHU S A
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMEr.rr (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
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, Jhat to the best
as to my right to enter into the,ma'ffrage"lltate.
21. SIGNATURE OF GROOM~
o 0 1ST 0 0
o 0 ~D 0 0
o 0 3RD 0 0
o 0 4TH 0 0
and belief that the information I provided is true and that I declare that no legal impediment exists
tl~ LN- fc:--
SEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED 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 ~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
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{ SEAL }
'-v-'
NAME (PRINT)
22. SIGNATURE OF BRIDE~
USE CURRENT NAME
DATE
05/15/2008
by New York Domestic
TIME
MONTH
MONTH
YEAR
YEAR
AM
03:57PM
2008
07
14 2008
05
16
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TYPE OF CEREMONY
o Ir'RELlGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY rvf#-l41t1
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
29. OFFICIANT
NAME (PRINT)
w'
TITLE
SIGNATURE~
DOH-98 (D3/2oo61
SPECIFY P j, ; hf)5 'fow V
,
31
NAME (PRINT)
SIGNATURE~