098
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
David Thomas WartaNski
COUNTY Dutchess
CITYfT.oW~ Wa~nger
. DISTRICT 1~
NUMBER
REGISTER 98
NUMBER
N
C
N
C
CD
,;
l'
~
I
ci
i
1
I
o
~
m
m
w
a:
Cl
Cl
<C
>-
U-
U
W
0-
m
~:I:Z
::It:Q
>-~>-
~~~
>-wZ
m....::;;
::JOW
::;;,,5
~~(/J
G~~
tl:oU)
0>->-
w~C3
sm1n
z~~
23. SUBSCRIBED AND SWORN TO FORE ME
SIGNATURE OF TOWN OR CITY CLERK~ DATE
This license authorizes the marriage in New York St person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies withi ew 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 'JOfiLE'e MasteIson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) .
SEAL SiGNATURE.... DATEOBf26I2OO5
'-v-I ppinger Falls, NY 12590
1. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)338-58-9D39
D. SOCIAL SE~WTY NUMBER
2. RESIDENCE A. InoIS B. Cook
(ST~) (COUNTY)
C. CHECK ONi-, ~!l" 0 TOWN 0 VILLAGE
~~~CIFY t:val DUoIII
D. STREET ADDRESS am Green1ee! street AI1 2 ZIP ~
E. IS REJiNCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE 3B. DATE OF BIRTH 02 /fIT /1974
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUEti OR BUSI'M~S scnooI DIS1I1ct 202
5. PLACE OF BIRTH cago, noIS
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Thomas Andre WartcMskl
B. COUNTRY OF BIRTH Germany
7. MOTHER
A. MAIDEN NAME Anna Kunach
B. COUNTRY OF BIRTH Poland
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DlVerCE CIVIL A'6ULMENT
w
>-
<(
>-
m
l-
S;
<C
C
w-
"U-
Su-
~<C
z
~
o
C:
>-
>-
13
Dl$TH
a:
w
"'
::;;
::J
Z
o
z
<(
>-
w
w
a:
>-
m
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
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
o
o
o
w
en
z
w
()
::::i
I
STATE FILE NUMBEH
(THIS SPACE FOR STA TE USE ONL Y)
11. A.
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME Aleda Rene HumDhrev
FIRST MIDDLE
--1
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Wartowski
(OPTIONAL - SEE REVERSE)On -56-12'" D
D. SOCIAL SECURITY NUMBER "IV
12. RESIDENCE A.lllinois B. Cook
(S~A ) (COUNTY)
C. CHECK ONE CITY 0 TOWN 0 VILLAGE
~~~CIFY Eva
D. STREET ADDRESs807 Greenleef Street AlA. 2
ZIP60202
~YESDNO
19'73
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE32 13.B. DATE OF BIRTH 08 r.J7
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATIONAttarneY
B. TYPE OF INDUSTRY OR BUSINESS C. G. L A.
15. PLACE OF BIRTHPouahkeegSle, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Richard Hum~rey
B. COUNTRY OF BIRTJJ SA
17. MOTHER
A. MAIDEN NAME Carol Mocarski
B. COUNTRY OF BIRTt-U S A
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D~ORCE CIVIL AOULMENT
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? DYES 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
o
o
o
IGNATURE OF BRIDE ...
ZIP
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.
STATE
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ?CATiJA+'f
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF )ll VILLAGE OF
SPECIFY U)L1) ...;;~\1'J6
TITLEr4~ f'~\El>"(
DATE ,O...m-2.00'6
L
