014
STATE OF NEW YORK I STATE FILE NUMBER I
] (THIS SPACE FOR STATE USE ONLY)
COUNTY Dutchess DEPARTMENT OF HEALTH
CITYfTOWN Wappinger
~~J~~~T 1~ AFADAVIT,UCENSEand
REGISTER 14 CERTIFICATE OF
NUMBER
., MARRIAGE Lo ~
SUPPLEMENTAL FILE
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME Stt~p.n c:; Rlldnir.k 11. A. FULL NAME Pia Ann Memala
FIRST MI LE CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Rlldnir.k
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. q_n
C. CHECK ONE 0 CITY
AND A"
SPECIFY ~RX
D. STREET ADDRESS 1!lS \Mlee Drive
ZIP
L iT3KS
YES o~O
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1?1-6(l.755R
2. RESIDENCE A. "!M) ynrlr B. g~~
C. CHECK ONE 0 CITY [JroI'rOWN 0 VILLAGE
AND
SPECIFY F_ Fi!:thkill
D. STRm ADDRESS n5 JA~n ~oad
B.~m
o ti/OWN 0 VILLAGE
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 26 38. DATE OF BIRTH
4. EMPLOYMENT
ZIP 1253S
DYES IJI"NO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
MO~ / ~,
MO
13. A. AGE 35
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION ~p.ms Administrsfil)n
B. TYPE OF INDUSTRY OR BUSINESS IBM.
5. PLACE OF BIRTH ~m:a1F ~)York
6. FATHER
A. NAME Robert S Budnick
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Joan E. S10vltt
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
A. USUAL OCCUPATION ~rsllld AnAtym'
B. TYPE OF INDUSTRY OR BUSINESS ~oy,,1 Bel'\k Of Cel'\ada
15. PLACE OF BIRTH ~I~p
16. FATHER
A. NAME Toomas Metsala
B. COUNTRY OF BIRTH Estonia
17. MOTHER
A. MAIDEN NAME Selma Leepere
B. COUNTRY OF BIRTH estonia
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
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B. HOW OlD 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
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
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
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I, being duly sworn, depose and say, that to the b st of my k owledge and belief that the information I provided is true and that I
as to my right to enter into the marriage state.
o 0
o 0
o 0
o 0
no legal impediment exists
21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Stat of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within 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
DATE 03lO9f.2004
by New York Domestic
~
{ SEAL }
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NAME (PRINT)
YEAR
YEAR
MONTH
TIME
MONTH
10
05
08 2004
03
ZIP
1~VIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /'
o CITY OF 0 TOWN OF ~ILLAGE
STR
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)
TITLE ~Ubh'~
SPECIFY
NAME (PRINT)
SIGNATURE ~
DOH-9B (11/98)
NAME (PRINT)
SIGNATURE
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