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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c; 1368
~~~I~~~R 142
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brian Edward Gromanly
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Jolanta Karwowski
MiDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Gromanly
(OPTIONAL. SEE REVERSE) 132-66-6490
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE) J (COUNTY)
C. CHECK ONE 0 CITY LJ TOWN 0 VILLAGE
~~~CIFY East Fishkill
D. STREET ADDRESS 1325 Route 82 ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
08 /24 )1'978
DAY
C. SURNAME AFTER MARRIAGE
(OPTiONAL - SEE REVERSE) 069-76-3966
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY I!'l TOWN 0 VILLAGE
~~~CIFY East Fishkill
D. STREET ADDRESS 110 Oak Ridge Road ZIP 12533
E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
12 / 24 / 1977
DAY
13. A. AGE 28
3. A. AGE 28
3B. DATE OF BIRTH
3B. DATE OF BIRTH
MONTH
YEAR
YEAR
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Programmer
B TYPE OF INDUSTRY OR BUSINESS Mount S1. Mary College
5. PLACE OF BIRTH New Rochelle, New York
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Edward Gerard Gormanly
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Eileen Regina Hanrahan
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Floral Designer
B. TYPE OF INDUSTRY QR BUSINl';;S Flowers By 1Wlhght
15. PLACE OF BIRTH YonKers, New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A NAME Stefan Karwowski
B. COUNTRY OF BIRTH Poland
17. MOTHER
A. MAIDEN NAME Ludmila Kuczynska
B. COUNTRY OF BIRTH Poland
1
1B. NUMBER OF .HIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI~RCE CIVIL AN~ULMENT
DE6TH
DE'3H
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
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) (C~TYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.ose and
as to my right to enter into th
21. SIGNATURE OF GROOM
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
best of my knowledge and belief that the information I provided is true and that I
o 0
o 0
o 0
o 0
that no legal impediment exists
/
09/06/2006
W
en
z
W
o
::;
23. sueSCRIBED AND SWORN T A
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
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 purpose of a second or subsequent ceremony.
24. TOWN OR CITY.J CI,.j::RKC M t 25 A SOLEMNIZATION PERIOD BEGINS
onn . as erson . .
NAME (PRINT)
YEAR
DATE
by New York Domestic
~
{ SEAL}
'-v-I
YEAR
MONTH
TIME
MONTH
09/06/2006
DATE
appinger Falls, NY 12590
SIGNATURE ~
MAim M~ffi
2006
11
09
07
AM
12:23pM
ZIP
STATE
27. TYPE OF CEREMONY
o ~IGIOUS
9 0 OTHER, SPECIFY
CITYITOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~j),-;/cJ~~ S'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY 4><d- f;,hK.: If
2::>
0'
TITLE
NAME (PRINT)
SIGNATURE~,
DOH.98 (0312006)
SIGNATURE~