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COUNTY ~
CITYfTOWN Wappinger
~~J:~c~ 1368
~G~~J~R 141
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Zbi . f'!tN Kunidci
MIDDfI"' CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~~fK8 E. PemnENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) '06~ ~n "~A"
D. SOCIAL SECURITY NUMBER ~
2. RESIDENCE A. New York B. DutchAlUL
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~OWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 7 Bell /lJr Lane ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGE :r1 3B. DATE OF BIRTH in / ':t1
MONtI1 rIA v
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c. S~~~~~JN~'Z~~~t~~e~~SE) KuRidci
D. SOCIAL SECURITY NUMBER Q64..68.1373
12. RESIDENCEA. N~EYor.k B. QW~88E
C. CHECK ONE 0 CITY D."KOWN 0 VILLAGE
AND Wa'
SPECIFY pp1ngt'"r
D. STREET ADDRESS 7 Bell Air Lan.
ZIP 125~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Q,;NO
McOB / Q,t, ~ aao
12~
YES []II' NO
/ yUP4
13. A. AGE 24
14. EMPLOYMENT
13.8. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Manufacl:uring
B. TYPE OF INDUSTRY OR BUSINESS IBM
5. PLACE OF BIRTH BleIAIc Pad-kl. PolAnd
(CITY, STATE/COUNTRY IF NUl USA)
6. FATHER
A. NAME Zenobh R7 Kunidci
B. COUNTRY OF BIRTH Poland
7. MOTHER
A. MAIDEN NAME Irena Rybacki
8. COUNTRY OF BIRTH Poland
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
A. USUAL OCCUPATION MIIRufacWRRg
B. TYPE OF INDUSTRY OR BUSINESS I. B. M.
15. PLACE OF BIRTH 't~LJN8N~.
16. FATHER
A., NAME RobeIt PeRin
B. COUNTRY OF BIRTH U S ft.
17. MOTHER
A. MAIDEN NAME Patl1e1s eennell
B. COUNTRY OF BIRTH U S ,/I.,
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
(2) 0 DEATH
o 0 0
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 ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
. 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
w
en
z
w
()
::i
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information 1 provided ntrue and that I declare that no legal impediment exists
as to my nght to enter into the marriage state. (""'-. a '7) ~
21 SIGNATURE OF GROOM ~ - \ " " 22. SIGNATURE OF BRIDE ~ 1~::5/5.s.O c, 1-0 LP ~ '- ')
SE C RRE U RRENT NAME
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK~ DATE
This license authorizes the marriage in New York. St 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
25. B. SOLEMNIZATION'PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL}
'-v-I
YEAR
MONTH
DAY
YEAR
NAME (PRINT)
SIGNATURE ~ .....
MAILING Al?DRESS
TIME
MONTH
AM
PM
01
11 2005
11
13
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT12",h..\""..lt i:., S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OFAJ VILLAGE OF
EoJJ,~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
29. OFFICIANT
NAME (PRINT)