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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c; 1368 .
~~~I~J~R 3
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mic~~ C Ysca~~~SURNAME
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FIRST Heather ~I~ Daniell~u~~~~AME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~~N1.~~~rEA~~~~~s};' s cavan is
D. SOCIAL SECURITY NUMBER 1 ?1-5R-Fi 111
12. RESIDENCE A. NY B. Dllt"hoss
(STATE) IC"l5llm?j
C. CHECK ONE 0 CITY ~ TOWN 0 VilLAGE
AND D hk '
SPECIFY ,0119 per~le
o STREET ADDRESS?66 ~;:Jlt Point Tllrnrike ZIP 1 /603
E. IS RESIDENCE wrrHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES -tJ NO
~~TH ~~AY ~~lJ
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 113-68-0707
2 RESIDENCE A. N'YsTATE) B. qM!r;;q~ss
C. CHECK ONE 0 CITY JlJ TOWN 0 VILLAGE
AND D bk '
SPECIFY ,0119 eepsle
o STREET ADDRESS ?R6 ~::llt Point TllrnrikA ZIP 1 ?R01
E. IS RESIDENCE WITHIN llMrrs OF CITY OR INCORPORATED VilLAGE? 0 YES olJ NO
M01Tt / ~~ / 1~8
13. A. AGE 3'1
14. EMPLOYMENT
A. USUAL OCCUPATION Self Employed
B. TYPE OF INDUSTRY OR BUSINESS RA::l1 F~t;:Jte
15. PLACE OF BIRTH H::lrdin r.n1lntv, KAntl Jr.ky
(CITY, STATE / COUNTRY1F NOT USA)
16. FATHER '
3B. DATE OF BIRTH
l-
S;
<(
c
3. A. AGE 39
4. EMPLOYMENT
A. USUAL OCCUPATION Csrp~nt~r
B. TYPE OF INDUSTRY OR BUSINESS Constp ICtion
5 PLACE OF BIRTH ~~,I~h~/~~Ji'T~t~'Nbilts'.:;' York
6. FATHER
A. NAME Rob~rt 4.nthony Y&lca"onis
B. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A. MAIDEN NAME Vita Felice D'::lndre~
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
A. NAME Peter \lincent Chadik
B. COUNTRY OF BIRTHI J ~ A
17. MOTHER
A MAIDEN NAME F;:Jith \!Arnnir.;:J .lonA~
B. COUNTRY OF BIRTHI J S A
18. NUMBER OF THIS MARRIAGE 3
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
3B. DATE OF BIRTH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) Iii'1 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTH / DAY / YEAR C. DATE LAST MARRIAGE ENDED? MONTt98 / ~A9 ,I. ~g,g7
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO
"
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0 1ST OR/10/?007 POllohkAAr~iA. NAw York
o 0 2ND 04/11/2000 Passaic County, New
o 0 3RD
o 0 4TH
my knowledge and belief that the information I provided is
,..
o
o
o
2
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that,to
as to my right to enter into the mar a S t ,
21, SIGNATURE OF GROOM ~
-;
. ts
22. SIGNATURE OF BRIDE
This license authorizes the marriage i 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,
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRIND
DATE 01/09/2008
by New York Domestic
~
{ SEAL }
'-v-I
YEAR
MONTH
YEAR
TIME
MONTH
AM
06:16 PM 01
10
2008
03
09 2008
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
CITY WN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
AM
PM
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
29. OFFICIANT
NAME (PRINT)
TITLE
SIGNATURE .-
MAILING ADDRESS
DATE
SPECIFY
STREET
30. WITNESS TO CEREMONY
CITYfTOWN
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRIND
SIGNATURE'-
DOH-98 (03/2D06)
NAME (PRINT)
SIGNATURE'-