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COUNTY D,Jtcl\~
W&pp"'g&r
1368
93
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Kenneth P Burkhardt
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
"I
CITYfTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Christina M. AnRelopoulos
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
"-
N
B BIRTH NAME, IF DIFFERENT
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Burkhardt
'(OPTIONAL - SEE REVERSE) ncn7A94OD
D. SOCIAL SECURITY NUMBER UO\I" At"'
12. RESIDENCE A. New York: 8. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 IIf"OWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 255 Smlthtown Road
12524
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER OQ1.S?33?7
2. RESIDENCE A. I\IP.\N Ynrlr B Dutchess
- (~TATE) . (COUNTY)
C. CHECK ONE 0 CITY O'lltOWN 0 VILLAGE
~~~CIFY I=i~hkill
D STREET ADDRESS 255 Smlthtawn Road
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
ZIP 12524
DYES o.fNO
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES o.fNO
07 /28 /1972
MONTH DAY
ZIP
3B. DATE OF BIRTH
YEAR
30
3. A. AGE 37
4. EMPLOYMENT
A. L1SUAL OCCUPATION Over Night stock Clerk:
B. TYPE OF INDUSTRY OR BUSINESS Priee Chopper
5. PLACE OF BIRTH (eP.Hgg_~tm~P York'
6. FATHER
13. A. AGE
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Secretary
B. TYPE OF INDUSTRY OR BUSINESS ArIstocrat Tours
15. PLACE OF BIRTH Yonkers. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME KennP-th Rurkh5Jrdt
B. COUNTRY OF BIRTH USA-
7. MOTHER
A. MAIDEN NAME Patricia Mary Hennessy
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
o 0
A. NAME John AngeloDOulos
B. COUNTRY OF BIRTH Greece
17. MOTHER
A. MAIDEN NAME HAlM Ann Newcomb
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
C. DATE LAST MARRIAGE ENDED?
13) 0 ANNULMENT
/ /
12) 0 DEATH
MONTH DAY YEAR
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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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
W
en
z
W
()
::i
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 that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the m.arri ge stat,.., ~ ~ ~
21. SIGNATURE OF GROOM ~ e,/U'l y::::, 22. SIGNATURE OF BRIDE ~
USE UR ENT USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ OA TE
This license authorizes the marriage in New York State 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
(17/1812003
,-^-.,
{ SEAL }
'-v-'
07
NAME (PRINT)
TIME
MONTH
YEAR
AM
02:~
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ld<",CJ.ItSWr
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF fi VILLAGE OF
SPECIFY J)o5&5 nfULY
. ,
SIGNATURE
nr....,j_QA f11JaA\