151
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
A~ &JI~ ~I
MIDDLE C R NT URNAME
:3
COUNTY Dutehess
CITYfTOWN Wapp.,
~~J~~c~ 1 ~
~G~~J~R 151
0-
N
I-
Z
W .
rn
w
ID
o
...I
::>
o
J:
rn
z
o
~
[[
I-
rn
a
w
[[
w
Cl
..
ii:
[[
..
::!
u.
o .
w
~
U
u:
;::
[[
w
U
w
[[
W
J:
~
rn
rn
w
[[
o
o
..
>-
u.
(3
W
0-
rn
(~
Z :i
[[ 0
::> ;::
Iii ..
[[ N
I- Z
rn ::!
::> w
::! 5
I- rn
Z
.. u.
(3 0
u:
u. rn
o ~
Iii 0
.... "'
o
z ~
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
1~-6f'.7125
2. RESIDENCE A. "tM VC'rIr B. ~e518
C. CHECK ONE 0 CITY 0 TOWN [NIttILlAGE
AND
SPECIFY \Ns:JppingP-I'K ~all!lI.
D. STREET ADDRESS ~ North ~lmOl'A AoulfNerd> 1'590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? O.tES 0 NO
3. A. AGE"Jl 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION W-.uy Mntnr J:qJ lip O~
B. TYPE OF INDUSTRY OR BUSINESS CoUntv 01 West.
5. PLACE OF BIRTH
T
F
A)
6. FATHER
I-
:>
c(
c
51!
..I.L
c(
A. NAME Anthnny ~ Jr
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME CIIIRC1r8 RomaR
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
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
. C. DATE LAST MARRIAGE ENDED? / /
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
YEAR
21. SIGNATURE OF GROOM ~
w
en
z
w
o
::i
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York
Relations Law ~11 to perform marriage ceremonies wi
o If checked, this license I
24. TOWN OR CITY CLERK
DATE
ate of the bride and groom named above by any person authorized by New York Domestic
n New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
to be used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL}
'-v-'
NAME (PRINT)
I'
l;TA II:: ~ILI:: NUMtll::H
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
11. A. FULL NAME FIRST 'Iltpdy A. U1~mNT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT KapysciaABki
C. S~~~JN~'Z~~:-~e~~SE) Umza Sa\.~RO
D. SOCIAL SECURITY NUMBER 13404-1547
12. RESIDENCE A.~;t'ar:k B. ~8SS
C. CHECK ONE D CITY D TOWN 0 .,II'ILLAGE
~~~CIFY VVappingew Falla
D. STREET ADDRESS 34 North Gllmor. Boldw8r~IP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? CJ9!'<ES D NO
13. A. AGE 38 13.B. DATE OF BIRTH McJII / at> /1Q65
14. EMPLOYMENT
A. USUAL OCCUPATION Un - Employed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH ~~~.,."., Volt
16. FATHER
A. NAME Paul KapysciIilr:l8ki
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Margaret retflela Hurley
B. COUNTRY OF BIRTH U is A
18. NUMBER OF THIS MARRIAGE :2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 0 Q
B. HOW DID LAST MARRIAGE END? (3) D -"ORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? ...,../ "'4 / ~~
MONTH I" DA~ l'I!lII!'l--
D. ARE ANY FORMER SPOUSE(S) ALIVE? D ~S 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
D 1ST
o 2ND
D 3RD
D 4TH
lief that the information
o D'"
o D
o D
o D
at no legal impediment exists
10(1412003 poughkeepsie, New Vork
22. SIGNATURE OF BRIDE
TIME
MONTH
YEAR MONTH
YEAR
11:4{~
11
.01
12 30 2003
ZIP
;~IVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~)
C. LOCATION O:fFONY
(CHECK ONE D SPECIFY)
D CITY OF TOWN OF D VILLAGE OF
SPECIFY ~~U~
NAME (PRINT)
SIGNATURE ~