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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
b.ndriy b.n~o\lych K~~~\1
FIRST R E
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COUNT'{nlltr.hp.!::!::
CITYfTOWNW~ ppi ngAr
~~~:~ 36R .
~5~1:~~"R 2
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FIRST N~t:::lliY13 J~Er!::i\ln:::l K~13kMDr' ~~RNAME
-.J
11. A. FULL NAME
"-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)..
D. SOCIAL SECURITY NUMBER 134-92-1551
12. RESIDENCE ANY BnlltchA!::!::
(STATE) (COUNTY)
C. CHECK ONE 0;{] CITY 0 TOWN 0 VILLAGE
~~~CI~ew York
D. STREETADDRESS149 Brighton 11th St: Apt 2a zIP11235
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? "1::J YES 0 NO
13. A. AGI=?A. 3B. DATE OF BIRTH 04 .A2 1-983
MONTH DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY
(STATE)
C. CHECK ONE III'D CITY 0
~~~CIFY NAW York
D. STREETADDREss149 Brighton 11th St: Apt 2azIP 11235
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGr;:24 3B. DATE OF BiRTH n? /13 /19R3
MONTH DAY YEAR
B. D(~fc;c;
TOWN 0 VILLAGE
4. EMPLOYMENT
A. USUAL OCCUPATION R~IA!::
B. TYPE OF INDUSTRY OR BUSINESS Food
5. PLACE OF BIRTJ<emerovo. Russia
(CITY, STATE I COUNTR't IF NOT USA)
6. FATHER
A. NAME Anatoliy Sidorovich Kudryavtsev
B. COUNTRY OF BIRTH Russia
7. MOTHER
A. MAIDEN NAME Olga Konstantinovna Miheeva
B. COUNTRY OF BIRTH Russia
8. NUMBER OF THIS MARF,lIAGE 1
14. EMPLOYMENT
A.' USUAL OCCUPATlo~tudent
B. TYPE OF INDUSTRY OR BUSINESsKinasborouah Comm
15. PLACE OF BIRTHZhvan. Ukraine
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMETaras Ivanovich Kostenuk
. B. COUNTRY OF BIRTtUkraine
17. MOTHER
A. MAIDEN NAMENadiva Tvmofivivna Stavnyuk
B. COUNTRY OF Blm-.Ukraine
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3)"6 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / . / C. DATE LAST MARRIAGE ENDED? 04 / 19 /2006
D. ARE ANY FORMER SPOUSE(S) ALIV~~NT~ YES 0 ~~ YEAR D. ARE ANY FORMER SPOUSE(S) ALlV~ YES 0 D~~ . . - YEAR
..
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) (CITYICOUNTY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR!. (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 04/19/2006 vinnitsa, Ukraine ~ 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, depose and say, thatt the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the mam, st riI ~~
21. SIGNATURE OF GROOM. \ 22. SIGNATURE OF BRIDE. if/.. Ql.1
USE USE CURRENT ~
23. ~::rf~=~Do~.fo~~Ocf~ J~A6~:E~ BEFORE ME DATE 08/02/2007
This license authorizes the marriage in New rk State of the bride and groom named above by any person authorized by New York Domestic
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 urpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY LERIS... . 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Jo v. Maste son
{SEAL SIGNATURE ~ DATE 08/02/2007 YEAR MONTH
'-v-I M~<Mr831~fb h Rd, W ppinger Falls, NY 12590 10 01 2007
STREET ClTYrroWN STATE
~~~:Ri~~J IO~O~~N~ZJ'~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY _ ..,,--
SONS NAMED ABOVE ON THE TIME AY YEAR 0 0 RELIGIOUS 1 ~IL
DATE AND AT THE TIME AND
PLACE INDICATED. ~ 'I 07 9 0 9THER, SPECIFY
BL
] CENTRE STREET
'f\~l
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
ZIP
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY
I')'Y
C. LOCATION OF CEREMONY
(CHe;!S-ONE AND SPECIFY)
!lYCITY OF 0 TOWN OF 0 VILLAGE OF
29. OFFICIANT
NAME (PRINT)
TITLE
2 9 AU6 20f1l
AJew YDI.."
SIGNATURE ~
MAILING ADDRESS
SPECIFY
STATE ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) NAME (PRINT)
SIGNATURE~~ SIGNATURE~
DOH-98 (0312006)
MUL TILINGUALSERVICES
3177 Coney Island Ave., Brooklyn, NY 11235
Tel. (718)646~COPY
Certified Translation, ID # 11-2104322
P ASSPORTOF CITIZEN OF THE UKRAINE
EC 927777
Page 7
~ PHOTO AFFlXED~
Last name:
First name:
Patronymic:
Date of Birth:
Place of Birth:
KUDRYAVTSEV
ANDRlY
ANA1;'OLIYQyYCH
February 13,1983
City' of Kemerovo
Signature ofthe passport owner: /signaturel
Page 2
Last name: ,KUDRYAVTSEV
First name: . ANDR!Y .
PatronYIl1ic: ANATOLIY9VYCH
Date of Birth: February 13, ;1983
Place of Birth: City of Kemerovo
Gender: Male
Issuer of the passport: Starokrymskoye Department of Militia ofKirovskiyRD
, CAMIA of Ukraine intheCrimea
Signature of the 'authorized person: (Signature); 08 May 1999; Seal attached;,
. AFFIDAVIT OF ACCURACY
I, Mikhail Shalmiyev, translator hereby declare,thatl am convers~t with English,
Russian andtJkrainian lang;uagesand that the translation made by me herein is to the best
of my knowledge and belief, a tI1letrarislation of the document submitted to me in
Russian and Ukrainian languages. .
Translator's signature
IU
Sworn to before me
This 2--GDayof
~q
Notary Public
L77 2007
.A~
ALICE ASHER
NOTARY PUBLIC; State of New York
No.01AS6062200
Qualified In Kings County
Commission Expires JuLY 30, 2009
MULTILINGUAL SERVICES
3177 Coney Island Ave.
. BrooklYn, NY J'1235
Tel. (71'8) 646~COPY
Certified Translation, ID.:#: 11.:.2104322
.T.f8SR. .
BIllTH> (1ERTIF1C4 TE
The Citizen:
Date of Birth :
Plac.eofbirth:
KUD~YAVT~~V, ANDRIY ANATOLIYO'VYCH
Febflla~ 13, 1983 . . '.'
City of Kemerovo, K{(merovp Reg\OIl,.'RSFSR
All ac(<?fhirthwasregistered iri the BookofBirthcRegistry .
on Februaty I?, 1983 rec.ord!5~7 .' '
'" .
PARENTS: .
Father:
Nationaiity:
'Mother: '
Nationality:
, . '.' ,- ." r,' - ," _ '_ "_" ~'.:
l(uDRYi\VrSEV;ANA.TOlilY SII)OROVICIl
Russimi.,., ", . , ..... ....., ..
,1(UPRYAVTS~VA,OL(jA KONSTANTINOYNA
Russian ,. , /
. Place . ofR.egis:try:
Date of issUe: .
. .
KemercivoCity Zil\GS
FebmiarylB, '1983
. '.' - .
Commiss{on,er of the Civil RegistrYOffice ';'(~igl1ed)
Se~l affixed .
'. .... ...... AFFIDAVI'fOFACCURACY
I, MikhaiL ~halmiyev; translatorhereby:gec.1are,that I am6qnversantwithEnglis4 and
Russian }a11.gllagesand thpttb,etranslation 'made, by me hereiIl' is to, the best of my
knowledge and belIef, a true translation ofthe;documeni submitted,to me'in Russian
"." " language. ' . '," '
Translator's signature' '..I\A......
.
Sworn to hefore, me
This . 26. .D. ~y Of. ;)t'l2007.
.....~ce~..
Notary 'Public'
ALICE ASHER
NOTARY PUBLIC, State of New York
No.01AS6062200
Quellfled In Kings County
Commission Expires JuLY 30,2009
MUL TILINGUAL SERVICES
3177 Coney Island Ave
Brooklyn, NY 11235
Tel. (718) 646-COPY
Certified Translation, ID # 11-2104322
Ukraine
CERTIFICATE OF MARRIAGE DISSOLUTION
Marriage between:
The Citizen:
and Citizen:
MEYDYCH, OLEG LEONIDOVICH
KOSTENUK, NATALIYA TARASIVNA
has been dissolved, which is registered in the Book of Marriage Dissolution Registry on
April 19, 2006 under the entry # 528
After the dissolution of marriage the above-named persons were awarded the following surnames:
Him:
Her:
Place of Registry:
Certificate is issued to:
Date ofIssue:
MEYDYCH
KOSTENUK
City ofVinnitsa the Civil Status Registry Office, Region of
Vinnitsa
KOSTENUK, NATALlY A T ARASIVNA
April 19, 2006
Commissioner of the Civil Registry Office (signed) G.M. Marchenko
Seal affixed
AFFIDAVIT OF ACCURACY
I, Mikhail Shalmiyev, the translator declare hereby that I am fluent in the English and
Ukrainian languages and that the translation done by me herein is to the best of my
knowledge and belief. This is the true translation of the document submitted to me in the
Ukrainian language. ;/ / r:/ _ p?
Translator's signature /L1 rU ~~
Sworn to before me
tzf
This ~ Day of
/l{k{
Notary Public
Serial I-AM No. 014462
2006
ALICE ASHER
NOTARY PUBLIC, State of New York
No.01AS6062200
Qualified In Kings County
Commll!lslon Expires JuLY 30, 2009
r-
MUL TILINGUAL SERVICES
3177 Coney Island Ave.
Brooklyn, NY 11235
Tel. (718) 646-COPY
Certified Translation, ID # 11-2104322
USSR
BIRTH CERTIFICATE
The Citizen:
Date of Birth:
Place of birth:
KOSTENUK, NATALIYA TARASIVNA
04/02/1983
village of Zhvan, Murovanokurilovetskiy Region,
Vinnitsa District, Ukrainian SSR
An act of birth was registered in the Book of Birth Registry
on April 27, 1983 record # 6
PARENTS:
Father:
Nationality:
Mother:
Nationality:
KOSTENUK, TARAS IVANOVICH
Ukrainian
KOSTENUK, NADIY A TYMOFIYIVNA
Ukrainian
Place of Registry:
Zhvan village division of ZAGS,
Murovanokurilovetskiy Region,
Vinnitsa District
April 27, 1983
Date of issue:
Commissioner of the Civil Registry Office (signed)
Seal affixed
III-AM No. 298732
AFFIDAVIT OF ACCURACY
I, Mikhail Shalmiyev, translator hereby declare, that I am conversant with English and
Ukrainian languages and that the translation made by me herein is to the best of my
knowledge and belief, a true translation of the document submitted to me in Ukrainian
language.
Translator's signature
Sworn to before me
This :;2 '7' Dayof J, :if 2007
~CP ~~
Notary Public
ALICE ASHEJit
NOTARY PUBLIC, State of New York
No.01AS6062200
Qualified I n Kings County
Commission Expires JuLY 30, 2009
NAlAJUftfA .jllC'aS'I'1BNUK
.~~1111Iil~II.llltlllll
2!71fil:11l0tZ!.9Sl7*
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