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COUN'rf Dutchess
. CITYITOWN Wappinger
~~~~~~T 1368
~G~~J~R 152
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
ChriHtopber: F Jiava
MIDDLE CURRENT SURNAME
STATE FILE NUMBER ~---,
(THIS SPACE FOR STATE USE ONLY) I
I
~
~~
1r /11 @O()'f)
~
Nbt USED
L 0 SUPPLEMENTAL FILE
A. FULL NAME
11 A. FULL NAME
FROM THE BRIDE
Lori A Sucich
MIDDLE CURRENT SURNAME
FIRST
FIRST
CL
N
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1"^ 1I:!-ft8663
D SDCIALSECURITYNUMBER _~_
2. RESIDENCE A, New Yark B. DutchP-ml.
(STATE) (COUNTY)
C CHECK ONE D CITY cYTOWN D VILLAGE
~~~CIFY Poughkee.pBie
D, STREET ADDRESS P. O. Box 1831 ZIP
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D
3 A, AGE 36 38. DATE OF BIRTH 12 09
MONtll / DAY
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Jiava
(OPTIONAL - SEE REVERSE)
D. SDCIAL SECURITY NUMBER 1Q9.58-7386
12 RESIDENCE A, New York: B DutchP-ml.
(STATE) (COUNTY)
C, CHECK ONE D CITY MOWN D VILLAGE
AND P hkee'
SPECIFY oug pBle
D, STREET ADDRESS P: O. Box 1831 ZIP 12590
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
13, A, AGE 32 13,B. DATE OF BIRTH 03 /11 ./-t971
MONTH DAY YEAR
12590
YES l'I NO
/l966
Y AR
4. EMPLOYMENT
14, EMPLOYMENT
A. USUAL OCCUPATION Travel Agent
B TYPE OF INDUSTRY OR BUSINESS Self Employed
15, PLACE OF BIRTH Pnllt'lhkeend.~ New York
(CI~E!COUN~F NOT USA)
16, FATHER
A NAME Mladen Sarich
8. COUNTRY OF BIRTH Vuravla
17. MOTHER
A, MAIDEN NAME Mary Dispensa
8. COUNTRY OF BIRTH II S A
18, NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A. USUAL OCCUPATION Deputy Sheriff
B. TYPE OF INDUSTRY OR BUSINESS Dutchess County
5. PLACE OF BIRTH ~2~y~~~
6. FATHER
A, NAME Alfred P .lava
8. COUNTRY OF BIRTH U $ A.
7 MOTHER
A. MAIDEN NAME Catherine Margaret Seckler
B. COUNTRY OF BIRTH II S A
8 NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
1 0 0
8. HOW DID LAST MARRIAGE END? (3) D~IVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 03 / ?1 / 'IQQ4R
MONTH D~ ~
D, ARE ANY FORMER SPOUSE(S) ALIVE? Dlll'Es D NO
2D, 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
8. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
03121/1994 Poughkeepsie, New York
D D 1ST
D D 2ND
D D 3RD
D D 4TH
ge and belief that the information I provided is true and t
D DI'
D D
o D
D D
I impediment exists
21 SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
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23. ~~J,fT~~~Do~Nlo~~O~RN ~~yBg~~~E DATE 10131/2003
This license authorizes the marriage in New York Stat of authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within w York State, THIS LICENSE VALID IN NEW YORK STATE ONLY,
n 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
25 B SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
NAME (PRINT)
YEAR
~
{ SEAL }
'-v-I
TIME
MONTH
YEAR
MONTH
DAY
AM
03:OS'M
11
01
12
30 2003
STR T
I CERTleY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
o D RELIGIOUS
9 D OTHER, SPECIFY
1 D CIVIL
A, STATE NEW YORK B, COUNTY
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF D TOWN OF VILLAGE OF
29 OFFICIANT
NAME (PRINT)
TITLE
SIGNATURE ~
MAILING ADDRESS
DATE
SPECIFY
STREET
30 WITNESS TO CEREMONY
CITYITOWN
STATE
ZIP
31 WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~
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COUN1.. DutchUII
> CITYITOWN YIIppIIlgIr
DISTRICT 1_
NUMl';ER
REGISTER 152
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
STATE FILE NUMBER ,0' ,...,
(THIS SPACE FOR STATE USE ONL Y) (!Jlltfl./kJc:;. I
/)f~ Nf-VfR ftJdK
;<17- tf(}~f Ptfl~ seE
NEld f-E&,'fJrEl? If
L 0 SUPPLEMENTAL FILE )
FROM THE BRIDE
L.ari A. Sucich
I
1. A FULL NAME
FROM THE GROOM
a-.iItapher F. ....
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
FIRST
MIDDLE
0-
N
B BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE ....
(OPTIONAL - SEE REVERSE) 1nil'lLII3L ~
O. SOCIAL SECURITY NUMBER ~, ~
12 RESIDENCE A New York 8 Dutches8
C. CHECK ONE (STAg) CITY O""'OWN 0 ViLLAGE (COUNTY)
AND O-~
SPECiFY .--..............--
D. STREET ADDRESS P. O. Box 1831
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1ftft---aaa":lIl
o SOCIAL SECURITY NUMBER ~
2. RESiDENCE A. New York B DuII:heIB
(STATE) (COUNTY)
C CHECK ONE 0. CITY [JIllrOWN 0 VILLAGE
AND o-.......-a
SPECIFY · .....~.
D STREET ADDRESS P. O. Box 1831
ZIP 12590
YES ~NO
/1971
YEAR
ZIP 12580
DYES l!I NO
I
E. is RESIDENCE WITHiN LIMITS OF CITY OR iNCORPORATED VILLAGE?
3 A. AGE 36 3B. DATE OF BIRTH
4 EMPLOYMENT
A. USUAL OCCUPATION ~ SheriIf
B. TYPE OF INDUSTRY OR BUSINESS Dutch!II! County
5. PLACE OF BIRTH ~. AI..
(CITY. STATE/cOlJirRY IF NOT USA)
6. FATHER
E is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? []
03 /11
MONTH DAY
13 A. AGE 32
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Travel ~
B. TYPE OF INDUSTRY OR BUSINESS Self Em~
15. PLACE OF BIRTH ~ New York
~fRYiFNC)T USA)
16. FATHER
A. NAME MI8den 8ucich
B. COUNTRY OF BIRTH v.,.- _1_"
17. MOTHER
A. MAIDEN NAME MtrY DIspense
B COUNTRY OF BIRTH U 8 A
18 NUMBER OF THIS MARRIAGE 2
'.
A. NAME Alfred P. ....
B. COUNTRY OF BIRTH USA
7 MOTHER
A MAIDEN NAME Cetbedne Mergaret Sedder
B. COUNTRY OF BIRTH U 8 A
8 NUMBER OF THIS MARRIAGE 1
PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. HOW DID LAST MARRIAGE END?
(31 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) O~VORCE (3) 0 ANNULMENT 12) 0 DEATH
C. DATE LAST MARRIAGE ENDED? m/ 21 / 1-..
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ollftos 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
0"Qi11'OO1 ~~'I tMwVtJ1ft
DEATH
o
DEATH
o
C. DATE LAST MARRIAGE ENDED?
YEAR
MONTH DAY
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. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
0'-'
1ST
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
ge and belief that the information I provided is true and t
o
o 0
o 0
o 0
I impediment exists
2ND
3RD
4TH
I, being duly sworn, depose and say, tha
as to my right to enter into the marriage s
21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
23 ~~J..fT~~~DO~N-?O~~O~~ ~~yBg~~~~E DATE 1001J2003
This license authorizes the marriage in New York Stat of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within w 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
~
{ SEAL}
~
NAME (PRINT)
. ~Uff~-
!fILING AD .
TIME
MONTH
DAY
YEAR
MONTH
YEAR
ZIP
AM
03:Q5'M
11
01
12
30 2003
STREET
I CE FY THAT I SOLEMNIZED
THE.- MARRIAGE OF THE PER.
SONS' NAMEp-' ABOVE ON THE -
. DIUE AND AT ,l~T.IME AND,
PLACE INDICATEpi' . '€ ., ,
~.-- ~~:E"'~-;',~'~~'",~, _'-'-'~,"
29 OFFleIAIII("''''''''':'lii~: '"
NAME (PRtrtJif:~_I;b; .r""',," . .
~Z;,fI!~k~;.,dC.,,;
"~j" -. f~.ti'.l
STREET
30. WITNESS TO CEREMONY
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
A STATE NEW YORK B. COUNTY
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF 0 TOWN OF 0 VILLAGE OF
TITLE
DATE
SPECIFY
STATE
ZIP
31. WITNESS TO CEREMONY
CITYITOWN
NAME (PRINT)
SIGNATURE ~
DOH--9~ (11/98)
NAME (PRINT)
SIGNATURE ~
/'