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COUNTY Dlltchess
CITYfTOWN WorrinaAr
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~5~I~J~R 13Fi
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rob~~Well:d Mi!ml~~NAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Cri~~E~AariA Nn[5~~ENT SURNAME
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0..
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. S~S~~M~~~rEA~~b~~s~~ i h a I ch i I<
D. SOCIAL SECURITY NUMBER 122-68-0697
12. RESIDENCE A. N Y 8. DIItr:hA~~
(iTATE) (COUNTY)
C. CHECK ONE 0 CITY Iii!' TOWN 0 VILLAGE
AND W .
SPECIFY ;:Jppmger
D. STREET ADDRESS 150 Chelsea Road
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER 129-6A.-68Fin-
2. RESIDENCE A. N (};ATE) B. Q~eSlii
C. CHECK ONE 0 CITY j;i!l TOWN 0 VILLAGE
AND \N .
SPECIFY ::lpplnger
D. STREET ADDRESS 1 FiO r.hel~e;:J Rn;:Jrl ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES tt'l NO
MO~W / J1~ / Y'\iU
ZIP. 12590
o YES~ NO
AQR4
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 23 3B. DATE OF BIRTH 09 ",?R
MONTH DAY
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3. A. AGE 33
4. EMPLOYMENT
A. USUAL OCCUPATION Technician
B. TYPE OF INDUSTRY OR BUSINESS Trillmph AI Itn. GI;:J~~
5. PLACE OF BIRTH Mnllnt Ki"l(~n "I""IM Ynrk .
(CITY. STATE I COUNTRY,IF-NOT USA)
6. FATHER
A. NAME Michael Thomas Mihalchil<
B. COUNTRY OF BIRTH I J S A
14. EMPLOYMENT
A. USUAL OCCUPATION Ph;:Jrm;:Jr.y Ter.hnid;:Jn
. B. TYPE OF INDUSTRY OR BUSINESS C V S
15. PLACE OF BIRTH Oueens, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME lohn.1 Nnrri~
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Lorraine M Jackson
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
3B. DATE OF BIRTH
7. MOTHER
A. MAIDEN NAME M;:Jry I=lIen Alex;:Jnrler
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
~
()
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. - YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
MONTH DAY
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
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
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en
1ST
2ND
3RD
4TH
I duly swear/affinn, depose and sa
as to my right to enter into ma
21. SIGNATURE OF GROOM~ \.
o 0 1ST 0 0
o 0 ~D 0 0
o 0 3RD 0 0
o 0 4TH 0 0
wledge and belief that the infonnation I provided is true and that I declare that no legal impediment exists
22. SIGNA RE OF BRIDE ~ ~ J'\.l)\tX.Jv\...:--(\f\ ~CJV)( ~
USE~
DATE 10/10/2007
USE CUR
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of th bride and groom named above by any person authorized by New York Domestic
Relations Law ~llto perfonn marriage ceremonies within New York S te. THIS LICENSE VALID IN NEW YORK STATE ONLY,
o If checked, this license is to be used 0 Iy for the purpose of a second or subsequent ceremony,
~ 24, TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) J
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ DATE 10/10/200
MAILlI'iG ADpRE~S AM
"-v-I 2u Mldale ppinQers Falls, NY 12590 01 :55PM 10 11 2007 12 09 2007
STREET ClTYrrOWN STATE ZIP
~~~~~RT~~J IO~O'r~~N:.z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR ol2l"'RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. II ',50 PM }O /3 ).",007 90 OTHER, SPECIFY
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY l0tst __\'\J41i
",,~~:IiI~~~~~ ' m,-," <uJ >-,u I~ Q
SIGNATURE~~ 1.,-' i I .)J~ATE. 1(9' /5-0'\
MAILING ADD
I '5"(P ~~~ C\L...<L"'~T\ '::50 \VI E..:?-S I ~ '--b l OS ~ '\
STREET CITYfTOWN ATE
30. WITNESS TO CEREMONY
NAME (PRINT) J~ yV\ a 1'\ a,~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY t.tl R t(..ft >-lor
NAME (PRINT)
SIGNATURE~