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COUNTY
CITYfTOW."J
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
..._ MARRIAGE
FROM THE GROOM
I
STATE FILE tlUMBER
(THIS SPACE FOR STA TE USE ONL Y)
Dutchess
WaPJ:inger
1368
146
L 0 SUPPLEMENTAL FILE
1. A. FULL NAME
MIDMattl1evi T. ar SURNAME
FROM THE BRIDE
ARST Talsiana M. ~")4QNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
11. A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) n~ft ~ A 8420
D. SOCIAL SECURiTY NUMBER -'Lo:lI!!Q!It!!_
2. RESIDENCE A. (~AX; B. (~
C. CHECK ONE 0 CITY 0 TOWN 0 ilIIlLAGE
~~~CIFY . WaPJ:ingem FallA
8216 Prln~ Cirt!lA
(J4().{)4.0788
12. RESIDENCE A. '"-V. B Ar..A..d
~sr Ale) . (1lo'IIWI1CliNt
C. CHECK ONE 0 CITY 0 TOWN 0 VII.LAGE
AND .,.
SPECIFY Vleppingers HIlls
D. STREETADDRESS 6216 PrIncess Circle ZIP 12590
E. is RESIDENCE WITHIN UMITS OF CnY OR INCORPORATED VILLAGE? 0 'J}s 0 NO
13. A. AGE 22 13.B. DATE OF BIRTH MoofiI'l / 048 / 119':11
14. EMPLOYMENT
D. STREET ADDRESS
E. IS RESIDENCE WITHIN UMITS OF CnY OR INCORPORATED VILLAGE?
3. A. AGE?3 3B. DATE OF BIRTH
12590
D~DNO
ZIP
W
I-
4. EMPLOYMENT
A. USUAL OCCUPATION SaleRl'nlln
B. TYPE OF INDUSTRY OR BUSINESS RIlSnlck's
5. PLACE OF BIRTH NewbJ.lrllh". Naiw Volle
(CITY, STA'i'EiCOi:Wi'R.. IFr<<iT"itSAT
6. FATHER
A. NAME Thomas Ellm
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary P Rln&g8R
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
o 0
o
(2) 0 DEATH
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH (cWlAIkcBeIarus USA)
16. FATHER
A. NAME MikMil MikheHawich AkseI.chyk.
B. COUNTRY OF BIRTH Belarus
17. MOTHER
:>
~
c
sU:
...u"
c(
A. MAIDEN NAME Allntlna Atldt.,.,,-na RezOIehenko
B. COUNTRY OF BIRTH Ukraine
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
DEATH
o
9 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MON1li DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUS\-Y DIVORCED OR ANNUlED, PROVIDE THE FOULOWING INFORMATION
DATE OF DEOOEE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, Y.EAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) AUVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNUUED, PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
a:
w
III
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1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief t at t e information I provided is true and that I declare that no egal impediment exists
as to my right to enter into the marr~ ~_ .. ,.
21. SIGNATUREOFGROOM~ URRENT 22.SIGNATUREOFBRIDE~ ~RRE~
23. SUBSCRIBED AND SWORN TO BEFORE ME '.
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York omestic
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. SOUEMNIZATION PERIOD BEGINS
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
MAI~ lftR
'-v-I STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
YEAR
TIME
MONTH
10
ATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
26. SOlEMNIZA
TIME
~g, = . E
~,"'~::;r~e
SIGNATURE ~ .'
MAILING ADORE _ "
II teES~R.II(Hr< r::>~.. WIJpPft.JGEJ2A'
STREET CITYfTOWN
30. WITNESS TO CERE
lP,CIVIL
A.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
I
SPECIFY /1J;;.PP trfG6IL-
TITLE h:..:>i~~ ~l":r..J~IC.;'i;t'2~l
DATE Nd 1/, ~..:tb(.l,~
FfH.;.S, M~ 12~q()
STATE
NAME (PRINT)
SIGNATURE ~
NAME (PRINT)
SIGNATURE ~ I~.