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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Edward T. Malle~
MIDDLE CURR NT SURNAME
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to the best of my kno
as to my right to enter into the m~ ;'fJe state. .~
21. SIGNATURE OF GROOM~- .
USEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK~
This license authorizes the marriage in New'~ Slate of the bride and groom named above by any person authorized by New York Domestic
Relations Law !l11to 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 (PRINT) J C. Master: TIME MONTH YEAR MONTH
{ SEAL SIGNATURE~ DATE 01/26/200
"-- -.J MAILJtlQ ~D.PIRF&~ AM 2007
-v- LU Mloall'appinger Falls, NY 12590 12:5&>M 01 27 2007 03 27
STREET CITY/TOWN STATE ZIP
~~~R~~RT~~J 'o~O~~~N~Zi~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 ~IL
DATE AND AT THE TIME AND
PLACE INDICATED. - 9 0 OTHER. SPECIFY
COUNTY Dutchess
CITYITOWN Wappinger
~~~~~c; 1368
~~~~J~R 6
1. A. FULL NAME
FIRST
D.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 067-62-0417
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE' 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY WappinQer
D STREET ADDRESS 45 Scarborough Lane Apt Q,P 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES & NO
04 / 05 / 1978
MONTH DAY YEAR
3. A. AGE 28
38. DATE OF BIRTH
....
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4. EMPLOYMENT
A. USUAL OCCUPATION Computer Engineer
B. TYPE OF INDUSTRY OR BUSINESS. Computer
5. PLACE OF BIRTH Svosset, New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME John Edward Malley
B. COUNTRY OF BIRTH U 8 A
7. MOTHER
A MAIDEN NAME Valerie Ann Limbach
B. COUNTRY OF BIRTH U 8 A
8. NUMBER OF THIS MARI;lIAGE 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 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S} ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLlLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
"'AI~ ~ILI: NUMBI:R
(TH/S SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Elena V. 8mirnova
MIDDLE CURRENT SURNAME
-.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 094-84-0581
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Queens
(STATE) (COUNTY)
C. CHECK ONE Cl" CITY 0 TOWN 0 VILLAGE
~~~CIFY Richmond Hill
D. STREET ADDRESS 87-17 102nd 8t, Apt D5 ZIP 11418
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? d' YES 0 NO
03 /26 /1975
DAY YEAR
13. A. AGE 31
3B. DATE OF BIRTH
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION ColleQe Professor
B. TYPE OF INDUSTRY OR BUSINESS. Education
15. PLACE OF BIRTH Leningrad, Russia
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Viktor N. 8mirnov
'B. COUNTRY OF BIRTH Russia
17. MOTHER
A. MAIDEN NAME Ludmila I. Vasilieva
B. COUNTRY OF BIRTH Russia
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULlMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
//
- YEAR
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S} ALIVE? 0 YES 0 NO
..
2D. 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
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
e and belief that the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE~ ;;, S-n-u~
USE CURRENT NAME
DATE 01/26/2007
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29. OFFICIANT
NAME (PRINT)
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNN"b, l~ )p ~ <;
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
ZIP
31. WITNESS TO H~~MONY
NAME (PRINT) \J ~'\ L~ (L\
SIGNATURE~