069
ll.
N
+
f-
Z
W
m
W
III
C
..J
::l
o
:t
m
Z
O'
>=
~
f-
m
a
W
a:
W
Cl
<(
ir
a:
<(
::;:
13'
W'
!;(
(.)
ii:
>=
a:
W
(.)
W
a:
W
~
m
m
W
a:
c
c
<(
it
5
W
0-
m
cr.'
W
III
~
::l
Z
C
Z
<(
Ii;
W
a:
Ii;
+
~:i::i
~!::Q
w~~
o:~_
f-wz
m..J::;:
::lUW
::;:Cl5
f-zm
z-
~~~
~O(l)
Of->
..wt5
l!!~",
o~
z::;;;:;
COUNTY Olltchp.ss
CITYfTOWN WFlppinger
~~~:~c~ 1368 .
~~~';~~R 69
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ed~Dgp Delgad2u~rURNAME
I
STATE FIL.E NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Trcc~lIM~r.hAIIA I AmR~~~SURNAME
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) ,
D. SOCIAL SECURITY NUMBER 060-66-373~
2 RESIDENCE A. N~TATE) B. ~!~~r
C. CHECK ONE 0 CITY W!J TOWN 0 VILLAGE
AND
SPECIFY 1.lnyrl
o STREET ADDRESS 54 Phillips Avenue ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY DR INCORPORATED VILLAGE? 0
3. A. AGE 38 3B. DATE OF BIRTH 1? / 1 A.
MONTR DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Alltn Rnrly Rp.pFlir
B. TYPE OF INDUSTRY OR BUSINESS Auto Elegance
5. PLACE OF BIRTH Faiardo, Puerto Rico
(cii"ii: STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME VIFlrlimir. IFlgr
B. COUNTRY OF BIRTH Czechoslavakia
7. MOTHER
A. MAIDEN NAME Sarah McAlavey
B. COUNTRY OF BIRTH Scotland
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. 81RTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~agr
(OPTIONAL - SEE REVERS
D. SOCIAL SECURITY NUMBER 077 -58-9911
12. RESIDENCE A. N r, B. III~tAr
( TATE) (COUNTY)
C. CHECK ONE 0 CITY Iii!' TOWN 0 VILLAGE
AND
SPECIFY I Inyd
D. STREET ADDRESS 54 Phillips Avenue
ZIP 12528
DYES I!J NO
;("q74
YEAR
12528
YES ~ NO
/ 1968
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 3? 3B. DATE OF BIRTH 10 /04
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION LJ nemplnyed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Newbur~h. New York
(CITY, STATE I OUNTRY IF NOT USA)
16. FATHER
A. NAME Rnger .Inseph Lempka
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Debbie L. Coonan
B. COUNTRY OF BIRTH USA
1 B. NUMBER OF THIS MARRIAGE 2
(2) 0 DEATH
2007
YEAR
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) LfDIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 07 / 25 / 2002
MONTH DAY ~ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? C(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
07/25/2002 Goshen, NY
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) ~DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 02/ 23 /
MONTH DAY,
D. ARE ANY FORMER SPOUSE(S) ALIVE? &(-ES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
02/23/2007 Ulster County. N Y
d
1ST
2ND
3RD
4TH
I duly swear/affinn, depose and say,
as to my right to enter into th IT
21. SIGNATURE OF GROOM~
d
o
o 0
o 0
o 0
pediment exists
o 1ST
o 0 2ND
o 0 3RD
o 0 4TH
ledge and belief that the infonnation I provided is true a
URE OF BRIDE ~
w
en
z
w
o
:::::i
USE.CU E
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK"
This license authorizes the marriage in New York State of t authorized
Relations Law ~11 to perfonn marriage ceremonies within New York te. 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 (PRINT) J C. Ma t
TIME MONTH YEAR
SEAL SIGNATURE"
'- -.J MA1'itj AA~~dfe AM 07
-v- 01 :56PM
09
15 2007
MONTH
YEAR
18
2007
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
~
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEWYORK B.cou~/$f-ey
c. LOCATION OF CEREMONY
(CHECK ONE AND ~IFY)
o CITY OF ~WN OF 0 VILLAGE OF
-
SPECIFY ~<; {)f u....5
TITL;1O W fl ::::JZ;.sf lee
DATEAJ!o . If ,0l007
~ N /,;l..'f.f&>b
STATE