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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
David J. Kolar
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutchess
CITYfTOWN WaDdnaer
~~J~~~ 1388
~5~\iJ~R 1~
I
L o SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME Jean Ann SctuMz
FIRST MIDDLE
CURRENT SURNAME
FIRST
CURRENT SURNAME
MIDDLE
a.
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Kolar
(OPTIONAL - SEE REVERSE) 1 02-54-4834
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA.NewYark B. Dutchess
(STATE) J (COUNTY)
C. CHECK ~ 0 CITY LI TOWN 0 VILLAGE
~~~CIFY uover
D. STREET ADDRESS5T HOllY Hit onve
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)Q58..64..6107
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New Yark B. Dutchess
(STATE) "". (COUNTY)
C. CHECKONE~CITY D TOWN 0 VILLAGE
AND ..........i
SPECIFY ~e
D. STREET ADDRESS Del B8Iso SOUIevard ZIP 1~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 41 3B. DATE OF BIRTH 01 /26 /1964
MONTH DAY YEAR
DAY
ZIP 12584
o YES~ NO
UBi
YEAR
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0)
4. EMPLOYMENT
A. USUAL OCCUPATION Engineer
B. TYPE OF INDUll~NESS I. B. M.
5. PLACE OF BIRTH H gIl. New York
(CITY, STATElCOUNTRY IF NOT USA)
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 39 13.B. DATE OF BIRTH 04 %4
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Glide Dog Instructor
B. TYPE OF INDU~T~Y OR BU~IJlI~~?_ GUlClng eyes
15. PLACE OF BIRTHAlb8ny. NeW' York
(CITY, STATE/COUNTRY IF NOT USA)
16; FATHER
A. NAME Michael John SchIJlz
B, COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Carol Ann Me Intyre
B, COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1a>RCE CIVIL ANaULMENT
D1jTH
6. FATHER
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A. NAME Edward John Kolar
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Eleanor Anne P&tterson
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVOdCE CIVIL AN&ULMENT
DE6H
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, 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 ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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o 0 1ST 0 0
,0 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
e best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
2 SIGNATUREOFBRIDE~~n^,--_~ '
~~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in ~ York Slat of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within W 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 C~I lER 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) . ~ _ TIME MONTH YEAR MONTH
SEAL SIGNATURE ~. DATE 09I28l2OO5
'-v-' M'20~ Rd, Wappinger Falls, NY 12590 01:31 AM 09 29 2005 11 Zl 2005
STREET CITYITOWN STATE ZIP PM
~~~~:R;~~~ 10~0~~~N~E~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0'Ol RELIGIOUS
DATE AND AT THE TIME AND ~ I"'" ~
PLACE INDICATED. ciil.eo PM 10 , 0;) 9 0 OTHER, SPECIFY
.....rcw,!::!; ~~~~L. I-\- · &:~
SIGNATURE ~ ~~~. ~_
MAILING ADDRESS
SJ"ET ~~(tr_\.\: ~~. &TYfT~tJ\i\)L\tJ (j.. ,
30. WITNESS TO CEREMONY
SUS
1l'?T
2ND
3RD
4TH
I, being duly sworn, depose and say, that
as to my right to enter into the marriage te
21. SIGNATURE OF GROOM ~
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YEAR
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2B. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY\)Itjl'"..~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF )it TOWN OF 0 VILLAGE OF
SPECIFY ~A-W L \ N \"'"
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
SIGNATURE ~