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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Kevin R KanKIN
MIDDLE - clii!!llENT SURNAME
COUNTY DutchIIs
CITYfTOWflj Wappinger
~~~:~crJ 1388
~Q~~J~R 103
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 062 ~ 1709
D. SOCiAL SECURITY NUMBER "O.l!::-
2. RESIDENCE A. N~rork". B. ~
C. CHECK ONE 0 CITY d TOWN r!J'VILLAGE
~~~CIFY Waooinaers Falls
D. STREET ADDRESS ~ WeSt Main street ttt- ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? r! YES 0 NO
3. A. AGE. 7.6 3B. DATE OF BIRTH n..":4 / nil / 1A7R
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Construction
B. TYPE OF INDUSTRY OR BUSINESS Self - EmplQyed
5. PLACE OF BIRTH North T,nut8AIft. New York
(CITY, STATetcoU~'~M USA)
6. FATHER
A. NAME Andrew RichardKarSl(y'
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Kef'ell louise KwocbkB
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULlMENT
o 0
DEATH
o
(2) 0 DEATH
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 ANNULlED, PROVIDE THE FOLlLOWING 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 ONL Y)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
MelUse... Lv"" I ee
MIDDLE .. CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE KaDSk:y
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 087.72.7120
12. RESIDENCEA. ~York B.~
C. CHECK ONE 0 CITY 0 TOWN ofvlLLAGE
~~CIFY Wappiogers Falls
D. STREET ADDRESS ~ WeSt Main Street ~ ZIP I 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? r!I YES 0 NO
13. A. AGE " 13.B. DATE OF BIRTH 4n /"':l A'oa4
~
14. EMPLOYMENT
A. USUAL OCCUPATION Order n..--"'or
B. TYPE OF INDUSTRY OR BUSINESS JOe Industries
15. PLACE OF BIRTH Bronx New York
(CITY, STAlE/COUNTRY IF NOT USA)
16. FATHER
A. NAME James Alfred lee
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Joan Veronica CozzI
B. COUNTRY OF BIRTH lJ S ~
18. 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) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES D NO
20. IF PREVIOUSLY DIVORCED OR ANNULlED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
D
22. SIGNATURE OF BRIDE ~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
nowledge and belief t~at the information I provided is true and that I
23. SUBSCRIBED AND SWORN TO BEfiORE ME
SIGNATURE OF TOWN OR CITY CLER~ ~
This license authorizes the marriage in New York S te of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies withi 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 CLE~K 25. A. SOLEMNIZATION PERIOD BEGINS
21. SIGNATURE OF GROOM~'
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{ } NAME (PRINT)
SEAL SIGNATURE ~
MA~<<dciebush R
~ 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)
DATE 08124/2004
by Ne~ York Domestic
TIME
MONTH
YEAR
ZIP
1 0:28AM
PM
08
1 tl CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY CtO.t\iI L
c. LOCATION OF CEREMONY ~
(CHECK .ONE AND SPECIFY)
o CITY OF 0 TOWN OF D VILLAGE OF
SPECIFY