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COUNTY ~
CITYfTOWN Wappinger
~I~~~W 1368
iiIlGISTER 130
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brian J. CselVak
MIDDLE CURRENT SURNAME
FIRST
r
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Kimber1y A Burke
MIDDLE CURRENT SURNAME
.-J
1. A. FULL NAME
11. A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 0877A1139
D. SOCIAL SECURITY NUMBER . .,..
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~OWN 0 VILLAGE
~~gcIFY WaDDinaer
D. STREET ADDRESS 148 Old HODeWIII Road
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Cservak
(OPTIONAL. SEE REVERSE) 11 ~7" '7449
D. SOCIAL SECURITY NUMBER ~ \I"
12. RESIDENCE A. New York B. Dutchess
(STATE) .' (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN D~ILLAGE
~gclFY WaDDinaers Falls
D. STREET ADDRESS 8 Veterans Place ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? c::1'YES 0 NO
13. A. AGE?R 13.B. DATE OF BIRTH M /11 /1R7R
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE?R 38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Sheet Metal Worker
B. TYPE OF INDUSTRY OR BUSINESS l..oceI 38
5. PLACE OF BIRTH ~!&J~iD'uX~
6. FATHER
A. NAME Jose,ph J. CBervak Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Nancy J:tebeool Do:yJe
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
ZIP 12590
o YES rfNO
14. EMPLOYMENT
A. USUAL OCCUPATION Child Care
B. TYPE OF INDUSTRY OR BUSINESS Self - EmplQyed
15. PLACE OF BIRTH (~~'~lT~ York
16. FATHER
A. NAME Thorn_ Joseph Burke. Sr.
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Joa~ne P,oJillJ
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
o
o
o
1ST
2ND
3RD
4TH
that the information I provided is true and th
21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
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23. ~~BrJ'Ac,.~=~oO~~o~~Ot,f ci~g~~i~E DATE 10101f2004
This license authorizes the marriage in New York bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit n New 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
{ } NAME (PRINT) Gloria J. Morse
TIME MONTH
SEAL SIGNATURE ~_ e TE
MAI~fiiCliebush R Falls NY 12590 11:49-M 10
~ STREET S ATE ZIP PM
~~~R~~~Ri~~ IO~O~~~N~~E~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 l'. RELIGIOUS
DATE AND AT THE TIME AND ~
PLACE INDICATED. 1- ~ I Cl A.; ~'i 9 0 OTHER, SPECIFY
~~~tr~w~~T G, ~'1 \Y . ~ ~cl ..~ TITLE rY"i -{ sf
SIGNATURE p-,--:' . _.. ". . ~ ~'~~ATE (01 ~"5 I a~
MAILING ADDRESS,/ f ,
11 ~\lV1J-t\V\ S~ W~pp~'V\~\t I". t=illf. ~"'Y. J/).t;'"YO
STREET CITYfTOWN --0 STATE ZIP
30. WITNESS TO S?BEMONY 31. WITNESS TO~EREMONY~
NAME (PRINT) NAME (PRINT) ~ I'Vj
SIGNATURE~ ~A~
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
Pvtc:..Jn "{ ~ c;
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF I1il. VILLAGE OF
SPECIFY VV c,. r f i Vtt.JJr S r-:VvU, ~