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COUNTY Dlltchess
CITYfTOWN Wappinger
~~~~~c;,T 1368
~~~~J~R 15
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
X~!Y M8R~~NT SURNAME
Mankievich
....
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
K~pn T. Ci~T SURNAME
-.J
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE. ..'
(OPTIONAL. SEE REVERSE) .
D. SDCIAL SECURITY NUMBER
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE C."BRAD . ......."... Ii-'-
(OPTIONAL. SEE REVERSE)"'" ,..,.- ........ ...."....... .
D. SDCIAL SECURITY NUMBER 072 72~ 1047
12. RESIDENCEA. N_NoFk B. Q~
C. X~6CK ONE c;j,I CITY 0 TOWN 0 VilLAGE
SPECIFY BeaOOR
D. STREET ADDRESS 1 0 Halfmoon Road ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
MOt /2S 19Z2
2. RESIDENCE A. ~E;V ark B. ~8Rd
C. X~6CK ONE 0 CITY l;,j,I TOWN 0 VILLAGE
SPECIFY MoRSe)'
D. STREET ADDRESS 32 Mo~ Boult\~ard .4\pl Gr
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGE 31 38. DATE OF BIRTH McD4 / 3..3
4. EMPLOYMENT
A. USUAL OCCUPATION General Centractor
B. TYPE OF INDUSTRY OR BUSINESS 1<105 COAStnlctJOFl
5. PLACE OF BIRTH ~NwMJm~
6. FATHER
1 D952
YES ~ NO
/~J
13. A. AGE JJ
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION Gymnastics Coach
B. TYPE OF INDUSTRY OR BUSINESS DyA8mle Gymnastics
15. PLACE OF BIRTH ~TN""Y;'i~fk
16. FATHER
A. NAME laItlfenoe Cioppe
B. COUNTRY bF BIRTH USA
17. MOTHER
A. NAME Germs(jy GnfJ9IYevish Mankiev-ieh
8. COUNTRY OF BIRTH Delsrus
7. MOTHER
A. MAIDEN NAME 1ge Mlkheylovne Petr'eeove
8. COUNTRY OF BIRTH FhlStlQ
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. MAIDEN NAME Kethleen Mo CatIerty
B. COUNTRY OF BIRTH Scotfand
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? '" 0 / ,(9 / IV'II'IA
MONTH 1 OAT ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? []jr'ES 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
000
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH OA Y 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
21. SIGNATURE OF GROOM ~
1 ST 1011912QQ4R~tI",ct~"tyl N y ~ 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that
as to my right to enter into the marriage state.
o
o
o
22. SIGNATURE OF BRIDE ~
w
en
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w
(.)
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23. SUBSCRIBED AND SWORN TO BEFORE
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York 5t
Relations Law !l11 to perform marriage ceremonies withi
o If checked, this license is
24. TOWN OR CITY CLERK
DATE
of the bride and groom named above by ny per n authorized by New York Domestic
ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
be used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL}
'-v-I
NAME (PRINT)
YEAR MONTH
YEAR
TIME
MONTH
DATE 03lO4l2OO5
AM
11:55PM
03 05 05 03 2005
28. PLACE WHERE MARRIAGE OCCUR~
A. STATE NEW YORK B. COUNT-dI'4.'lZ~
C. LOCATION OF CEREMONY
(CHECK ONE AND )PECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY f6u...b~~
ZIP
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICAT
10 CIVIL
NAME (PRINT)
SIGNATURE ~
DOH.98 (11/98)