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COUNTY Dutchess
CITY/TOWN \Nappinger
~~~~~crJ 1368
~5~~J~R 140
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
N_J)aniel K~ SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~ M. 6tabiltENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
a.
N
B BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Camenisch
C. S~~~~~N~~~~~t~~e~~SE)KucerB
D. SDCIAL SECURITY NUMBER 134-38-n61
12. RESIDENCE A. NI~ATE) B. Quteh~
C. ~~5CK ONE 0 CITY CVOWN 0 VILLAGE
SPECIFY '.^Jappinger
D. STREET ADDRESS 95 New Hackensack Road, ZIP 12590
E. IS RESIDENCE WITHiJ.J L11>hs'U'cfrv OR INCORPORATED VILLAGE? 0 YES ~ NO
MJJa / Q3 ~95Q
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 344 42 9548
2 RESIDENCE A ~ V B ~ess
,S"",TE) . ~M'I')'
C ~~5CK ONE 0 CITY ~TOWN 0 VILLAGE
SPECIFY Wappinger
D. STREET ADDRESS 95 New Hackensack Roa~ ZIP
E IS RESIDENCE WITHi~ LIMITS OF~ITv OR INCORPORATED VILLAGE? 0
.rnl/
MOiWl'll ~8
125g()
YES ~ NO
/ y1.:)48
3. A. AGE 55
4. EMPLOYMENT
13. A. AGE 53
14. EMPLOYMENT
38. DATE OF BIRTH
13_8. DATE OF BIRTH
A. USUAL OCCUPATION Robotic Technician
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH g"'I&f?&JN~~SA)
6. FATHER
A. USUAL OCCUPATION Assistant ComptrGller
8. TYPE OF INDUSTRY OR BUSINESS sterling Promotional Corp
15. PLACE OF BIRTH M'-~~N.u~prk
16. FATHER
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A. NAME stanley John Kucera
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Marie Jesephlne Dude
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. NAME Raymond Koch
8. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Marte Camenlsch
8. COUNTRY O,FBIRTH U S ^
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
100
B. HOW DID LAST MARRIAGE END? (3) MIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTH 04/ OAQfJ / 2Q03
D. ARE ANY FORMER SPOUSE(S) ALIVE? [lwItES 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
1 0 0
8. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? Q3/ n&: / ~a'7l:
MONTH D_ ~1!l(1'I U
D. ARE ANY FORMER SPOUSE(S) ALIVE? [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
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1ST 04109I2OO3 DLlchl. Co., NY 0 Owl' 1ST 03J06l1975 Santo Domingo, Dnmb. 0'; 0
2ND 0 0 2ND - Repu l1c 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the marriage stat ,;..,/ . . ~ /. D' .
21. SIGNATURE OF GROOM~ ~~~~
-USE C~NT NAME
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE 10106I2OO3
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York DOf11estic
Relations Law ~11 10 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 PERIOD BEGINS
~
{ SEAL }
'-v-'
NAME (PRINT)
SIGNATURE ~
MAILING ADDRES
TIME
MONTH
YEAR
MONTH
YEAR
10
07
12
05 2003
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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 1)
NAME (PRINT) n
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 ~ VILLAGE OF
SPECIFY
SIGNATURE ~