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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFRDAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ken~ H HelI"NlIri II
MIDDLe' - cUl'iFi~SURNAME
COUNTY Dutche55
CITYITOWN Wappinger
Sl~:fRT 1388
REGISTER 134
NUMBER
1. A. FULL NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 400V\.1:!ft '1280
D. SOCIAL SECURITY NUMBER -I~_
2. RESIDENCE A. G9l~ B. ----ft'~eld
C. CHECK ONE [ill CITY 0 TOWN 0 VilLAGE
AND
SPECIFY RmnmfiP.ld
D. STREET ADDRESS ~1 \NMt 1~ AVAnUA ZIP ~
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? ~ES 0 NO
MoJ~ / ~ / JI17
3. A. AGE 2S
4. EMPLOYMENT
A. USUAL OCCUPATION Air pnlllllinn T~N
B. TYPE OF INDUSTRY OR BUSINESS Alrtecb Environmental
5. PLACEOFBIRTH~Yor.k
6. FATHER
3B. DATE OF BIRTH
A. NAME Kennelb Henry HelcasIci
B. COUNTRY OF BIRTH IJ S A
7. MOTHER
A. MAIDEN NAME Clrol Ann MlOIrohlok
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) 0 DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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, STA~OUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
1ST
2ND
3RD
4TH
I, being duy sworn, depose and say, that to the best of my kno
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM ~
I"
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~Fn C ~lENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE HBlcaski
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 082.7Q. 7300
12. RESIDENCEA.~ B. ~l~eld
C. CHECK ONE ~CITY 0 TOWN 0 VILLAGE
AND
SPECIFY9rnnmfiP.ld
D. STREET ADDRESS ~1 \NMt 129th AVAnUA ZIP 8OCQO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? [Y'YES 0 NO
13. A. AGE 24 13.B. DATE OF BIRTH M~ / ~~ ~~p
14. EMPLOYMENT
A. USUAL OCCUPATION T..;"gP- Qnnrrif'tJdnr
B. TYPE OF INDUSTRY OR BUSINESS stdlne
15. PLACE OF BIRTH _~..~ York
16. FATHER
A. NAME Giliab 0esIi
B. COUNTRY OF BIRTH, Ind.
17. MOTHER
A. MAIDEN NAME Donna HarlGW
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
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
YEAR
o D
o D
o D
o D
declare that no legal impediment exists
<LQ"\,Q~>oo .1
USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO BEFORE ME ..........."'''''"'''...
SIGNATUREOFTOWNORCITYClERK~ DATE ~::!
This license authorizes the marriage in New York bride and groom named above by any person authorized by New York Domestic
Relations Law ~11to perform marriage ceremonies wit New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If cheeked, this license is to be used only for the pur ose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL }
'-.-'
NAME (PRINT)
SIGNATURE ~
MAILING AD,?RESS
STAE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TIME
MONTH
YEAR
AM
12:3O"M
10
~ RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY oA"chc.S:
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF '5l TOWN OF 0 VILLAGE OF
SPECIFY Hyde Po.rK
, 0 - 04 -0.3
\-\-0 \ rnes
~
DATE
2-
29. OFFICIANT -r-1...
NAME (PRINT) " 10 mt).S
SIGNATURE ~_~
MAILI G ADDRESS
Leo
TITLE
y
?a.s-to r
lCJI/)4/t!J3
12-0570
STATE ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) "\'C~v~ h G:.Cl'\"Gpr-
SIGNATURE ~ ';....IJo.,,;[