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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Timcatt!~ James CM~fsURNAME
18T D D 18T D D
2ND D D 2ND 0 D
3RD D 0 3RD 0 D
4TH D 0 4TH 0 D
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 I declare that no legal Impediment eXists
as to my right to enter Into the marriage state. ~
21 SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~ ~ )J. M h~
. ' USE CUI'lI'lENT NAME
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK~ DATE 06f25D004
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage 'ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
.~_.....",j:';]"'lf'~ecked..this.lloense'isto be used only tor,the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK '25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY Dutche-ss
CITYfTOWN VV.appinge-r
~~~~~CRT 13GB
~5~~J~R 66
1. A. FULL NAME
FIRST
a.
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SDCIAL SECURITY NUMBER 058-60-7089
2. RESIDENCE A N I~ATEI B. q~esli
C. CHECK ONE D CITY ijt TOWN D VILLAGE
~~~CIFY East Fishkill
D STREET ADDRESS 203 Robinson Lane ZIP 1259n
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
M~ / "ni / 1RW
3B. DATE OF BIRTH
3. A. AGE 37
4. EMPLOYMENT
A. USUAL OCCUPATION Project Manager
B. TYPE OF INDUSTRY OR BUSINESS IBM Corp
5. PLACE OF BIRTH ~c~~~~~~"'~U};)
6. FATHER
....
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A. NAME Br11ct" CllrtiSS
B. COUNTRY OF BIRTH "S~
7. MOTHER
A. MAIDEN NAME Madeline Haskett
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
DEATH
o
(2) D DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
(3) D ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
1 D. 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
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NAME (PRINT)
I
STATE FILE NUMBEH
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
SUZitQQ.f M. .AJbaQ~~T SURNAME
.-J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE rUmS!;
(OPTIONAL. SEE REVERS~
D SOCIAL SECURITY NUMBER 079-64-4659
12. RESIDENCE A. N XTATE) B. D~~
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~~CIFY East Fishlcill
D STREET ADDRESS 20:3 Rnhi~on t Anp. ZIP 1?5~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES Ii'! NO
JJlH /O~AY {911R
13. A. AGE 26
14. EMPLOYMENT
A. USUAL OCCUPATION Te-acher
B. TYPE OF INDUSTRY OR BUSINESS Arlington Cntrl Shl
15. PLACE OF BIRTH ~~~cr;tm IYN'i?!t\AI
16. FATHER
A. NAME .1~J'h .Inhp Albfln~p
B. COUNTRY OF BIRTH'I S A
17. MOTHER
13.8. DATE OF BIRTH
Dis!
A. MAIDEN NAME Barbera Krystyna Irk~JSki
B. COUNTRY OF BIRTH Poland
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(21 D OEA TH
o
o
B. HOW DID LAST MARRIAGE END? (31 D DIVORCE
(31 D ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
TIME
MONTH
YEAR
MONTH
YEAR
DATE nRD~
AM
12:37 PM 06
26
2
08
24 2004
ZIP
CI
26. SOLEMNIZATION OCCURRED
.,_ ..HAolE. .,.., ,.. ..M .. . DAY YEAR
AM
5'00 PM
STATE
27. TYPE OF CEREMONY
D ~ELIGIOUS
9 D OTHER, SPECIFY
1 D CIVIL
A. STATE NEW YORK 8. COUNTYjJ()~He!S.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF ~TOWN OF D VILLAGE OF
SPECIFY EIJf;r ~1.; ICLC~
.
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
0]0.4
29. OFFICIANT
NAME (PRINT)
TITLE
SIGNATURE ~
MAILING ADDR
..s c:J1
STREET
30. WITNESS TO CEREMONY -J-I--
,~, '"'''' ~~~. rr, li:;k-e ~
SIGNATURE ~ U ~ Ch-, '-L. /
DOH.98 (11/98)
28. PLACE WHERE MARRIAGE OCCURRED