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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jos~Rtorn1~roliila\.M ~~itWij!~NAME
COUNTY [)IJtchess
CITYiTOWN Wappinger
~~~:~~ 1 :iRR
~~~I;;~R R
1. A. FULL NAME
FIRST
tl.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 058-46-97.:18
2. RESIDENCE A. NV B. n'lt,..h~liiS
1STATEI ~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY East Fishkill
o STREET ADDRESS .:17 \Nrioht Rlvrl ZIP 1 ?Fi:i:i
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES eJ NO
MO'Xl / JJJJ / ylj53
3. A. AGE 54
4. EMPLOYMENT
A. USUAL OCCUPATION Chemigtry T8chnicilim
B. TYPE OF INDUSTRY OR BUSINESS Energy" Itility
5 PLACE OF BIRTH ~~nnfltt~n New York
( , ST / OUWrRY IF NOT USA)
6. FATHER
3B. DATE OF BIRTH
A. NAME Josef Matwijiw
B. COUNTRY OF BIRTH Ilkraine
7. MOTHER
A. MAIDEN NAME Miilriiil Bobyk
B. COUNTRY OF BIRTH Ukriiline
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER.OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
1D. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNT~~.IF N.QT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
D~ldna M Arm~j~RENT SURNAME
-.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 074-Fi4-1771
12. RESIDENCE A. N";'STATE) B. D(~rss
c. CHECK ONE 0 CITY Ii;il' TOWN 0 VILLAGE
~~~CIFY F:::l~t Fi~hkill
D. STREET ADDRESS 47 Wright Blvd ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 50 3B. DATE OF BIRTH ~TH /~Y ~~ii7
14. EMPLOYMENT
A. USUAL OCCUPATION Homemaker
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH M~,~~~~C~~'rf'l~YNOT USA)
16. FATHER
,A. NAME Philip A.rmeli
B. COUNTRY OF BIRTH I J S A
17. MOTHER
A. MAIDEN NAME Gloria Martz
B. COUNTRY OF BIRTH I I S A
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
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
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 tru
as to my right to enter into the ma age state, , . . .
21. SIGNATURE OF GROOM ~ ' 22. SIGNATURE OF BRIDE ~
23. SUBSCRIBED AND SWO N IAFFIRM BEF
SIGNATURE OF TOWN 0 CITY CLERK ~
This license authorizes the marriage in New York 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.
R ITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
(PRI J~~
AT E~
ADDRESS
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en
z
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o
:::::;
~
{ SEAL }
'-v-'
DATE
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
o 0
o 0
o 0
o 0
impediment exists
DATE
02/1 Q/2008
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
02/19/2008
02
20
2008
04
19 2008
qO
ZIP
31. WITNESS TO CEREMONY
2B. PLACE WHERE MARRIAGE OCCUR~ . .
A. STATE NEWYORK B.COU~"~";'S"
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY U} /). fI ; J~ ,--
NAME (PRINT)
SIGNATURE~