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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brian M"~ Kowalczyk
FIRST MIDDLE
COUNTY Dutchess
CITYrrow~ VV8ppingef
DISTRICT',368
NUMBER
REGISTER 47
NUMBER
1. A. FULL NAME
CURRENT SURNAME
"-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 104-58-8584
D. SDCIAl SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) J (COUNTY)
C. CHECKON~ITY J:I.TOWN 0 VILLAGE
AND
SPECIFY
D. STREET ADDRESS ti2 Del B8ISO SOlIeVerd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR iNCORPORATED VilLAGE? 0 YES ~ NO
OS /10 /1972
DAY
3. A. AGE 33
3B. DATE OF BiRTH
MONTH
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Chef
B. TYPE OF INDU~SINESS 5eII' Employed
5. PLACE OF BIRTH lBePl". New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME RonsId John Kaw8Iczyk
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Joenne Mar.. Clsslano
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRiAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHiCH ENDED BY
DIVcaCE CIVIL AN&ULMENT
D~TH
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 ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME Neale Lynn Donovan
FIRST MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Donovan-Kawalc::2:Yk
(OPTIONAL - SEE REVERSE) "IHIL - 7188
D. SOCIAL SECURITY NUMBER UUir"' ,c,.
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND ~
SPECIFY e
D. STREET ADDRESS Road
E. is RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 29 13.B. DATE OF BIRTH t.rl .liJ
MONTH DAY
ZIP 12590
o YES~ NO
19'75
YEAR
14. EMPLOYMENT
A. USUAL OCCUPATiON Teecher
B. TYPE OF INDUSTRY OR BUSINESS w. c. S. D.
15. PLACE OF BIRTH CoIcISprlna.NewYork
(CITY, STATElCOUNTRY IF NOT USA)
16. FATHER
A. NAME Patrick: Ch8Ites Donavan
B. COUNTRY OF BIRTHU SA
17. MOTHER
A. MAIDEN NAME UndI Mary Bermel
B. .COUNTRY OF BIRTHU SA
lB. 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
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
o
o
o
. SIGNATURE OF BRIDE ~
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1ST
2ND
3RD
4TH
I, being duly sworn, depos
as to my right to enter i the
21. SIGNATURE OF GROO
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
the best of my knowledge and belief that the information I provided is true and t
23. SUBSCRIBED AND SWORN TO BEFORE ME.
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York Sta bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within 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 CI LE't: 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
t-"-.
{ SEAL }
'-v-I
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
DOH-98 (11198)
TIME
MONTH
YEAR
MONTH
YEAR
:31
AM
PM
06
22
2005
08
20 2005
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~~He'S~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~GE OF
SPECIFY Wff~A.>v6'€A.S j:;qus
10 CIVIL
((.c. ;7..e il?Sr
.., /30(cS-
I ;2.S9
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) l:)ct n 1.e.11~. Do VI 0 VO-Y)
SIGNATURE ~ _Dt11ll.QJL.a. ~oa..Yl