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COUNTY Dutch~t;,
CITYfTOWN Wappil'\ger
~~~:~c; 1 ~8
~5~I~J~R 8
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MLmfel G. Bru!t~E~SURNAME
5TATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~ L RUSGta&NT SURNAME
..J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
11.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~JN~~~~~~~~~SE) SNAG
D. SOCIAL SECURITY NUMBER 084 64 8215
12. RESIDENCE A. ~~TE) B. ~'8S8
C. ~5CK ONE 0 CITY 0 TOWN 0 ~LLAGE
SPECIFY Wapplngel5 Falls
D. STREET ADDRESS 4. No. Mesler Avenue, Apt. ~ 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? D~ES 0 NO
13. A. AGE 24 13.B. DATE OF BIRTH MO~ / 30 / ~
14. EMPLOYMENT
A. USUAL OCCUPATION Caok
B. TYPE OF INDUSTRY OR BUSINESS Comer stone (rehab)
15. PLACE OF BIRTH ~NXQfk
16. FATHER
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
On-5a..3125
B. (Q~esl
C. CHECK ONE 0 CITY 0 TOWN D"-ILLAGE
AND
SPECIFY Ws:JpplngP-~ Fells
D. STREET ADDRESS A N~ MAdAr AVA""A, Apt A 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D.,tES 0 NO
3. A. AGE 32 3B. DATE OF BIRTH MO~ / oQ5 / yJ.B7
4. EMPLOYMENT
A. USUAL OCCUPATION F~ Servia- Director
B. TYPE OF INDUSTRY OR BUSINESS Nt ddtlon Mgmt. Corp.
5. PLACE OF BIRTH (~~.Yolt
6. FATHER
2. RESIDENCE A.
~TXE)
A. NAME Midtael George Bruno
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME Eva AtterIIAg
B. COUNTRY OF BIRTH SWeden
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. NAME stephen \^Alliam Ruschak
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Kathlo Leo V.'",'8M
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) 0 1IllIv0RCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? Q51'.,., / 'IClO'i:
MONTH OAva-' yE1i~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 ~S 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
05IJ2I1985 Br~'I8rc1 Co., FloFlda
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
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
D~ 1~ 0 0
o 2ND 0 0
o 3RD 0 0
o ~H 0 0
nd belief that the information provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ ti.r~us~i~R~~M-2c.J.lttJ(-
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within 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 P!'RIOD BEGINS
DATE
by New York Domestic
~
{ SEAL }
'-.t-'
YEAR
YEAR
MONTH
TIME
MONTH
04 18 2004
28. PLACE WHERE MARRIAGE OCCURR~
A. STATE NEW YORK B. COUN~~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
02
19
SPECI
JJ.ifD .<..i:A P /Iv ~ r /P~';../
~(jG.--,-,~J
SIGNATURE ~