014
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affinn, dep.ose and say, that to the best of my knowledge and belief that the infonnation I provided is true
as to my right to enter into the ~m~e sIB e.
21.SIGNATUREOFGROOM~ ~'. '. .SIGNAT EOFBRIDE~
U CURRE
23. ~:~~~~DO~~~~~~ ci~Abr~R~E~ BEFORE ME DATE 03/01/2007
This license authorizes the marriage in New York State of the authorized by New York Domestic
Relations Law ~11 to perfonn marriage ceremonies within New York SIB THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be usad only for the urpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Jo
{TIME MONTH YEAR MONTH
SEAL SIGNATURE~ TE 03/01/200
MAILING ADDRESS 09'2'1t.M
'-v-I 20 Middl NY 12590 . c 03 02 2007 04 30 2007
STREET STATE ZIP PM
I CERTIFY THAT I SOLEMNIZED 27ZTYP F CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE 0 RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Willi;:J~oJ~hn K07Ioct~~~sd~ME
COUNTY Dutchess
CITYITOWN WappinQer
~~~:~c; 1368 .
~~~~~R 14
1. A. FUll NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 094-72-0887
D. SOCIAL SECURITY NUMBER ___ __ ___
2. RESIDENCE A. Np.w York B. DlJtchp.~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN IY VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 66 Pagai Terrace ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 01 YES 0 NO
3. A. AGE ~? 3B. DATE OF BIRTH 04 / 04 / 197
MONTH DAY YEAR
4. EMPLOYMENT
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LL.
<
A. USUAL OCCUPATION Corrp.ction Officer
B. TYPE OF INDUSTRY OR BUSINESS N Y S Dept. Of Corr.
5. PLACE OF BIRTH Bronx. New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Willi;:Jm K07low~ki
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary Ann Ewart
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEA'jli
MONTH MY 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
(MONT'H, DAY, YEAR) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
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SIGNATURE~
DOH-98 (0312006)
12 f I
'v 1>\$ C I 0.11 I
'......
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kim~~~~~ Anne V~~~R~~~URNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Kozlowski
(OPTIONAL - SEE REVERSE) 081 72 8733
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. New York 8. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN []I VILLAGE
~~~CIFY Waopinaers Falls
D. STREET ADDRESS 66 PaQQi Terrace ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? Lf YES 0 NO
13. A. AGE 30 38. DATE OF BIRTH 10 / 15 /1976
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Domestic Engineer
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Brooklvn. New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard J. Votypka
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Lorraine Joanne Buono
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. ..- YEAR
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o 0
o D
o 0
o 0
clare that no legal impediment exists
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. couNr..:!2IA.TC/{Cs;<;;.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
o CITY OF 0 TOWN OF ~LLAGE OF
SPECIFY Vt./;;-{JfJ1 ^J~r;?.s rA U,.g
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