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083 0- N .... :> <t c u:: u. z <t a i= <( a: >- (/) (5 w a: w C9 <( cr:" a: <( :2 LL a w >- <( 0 u: i= a: w 0 w a: w a: I ~ UJ lD (/) " (/) ::J W Z a: 0 0 z 0 <( <( >- >- UJ UJ LL a: 0 >- w {/) 0. (/) W en z w () ::i Z:i:::i. ~~3 UJ ~~~ I- >-ffiz <t ;gd~ () ~~~ u:: z- 6~6 j:: [to{/) a: 0>->- W wtJ5C3 () b~U1 Z::i~ STATE OF NEW YORK DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE FROM THE GROOM R~ P Fati_ENT SURNAME 1ST D D 1ST 10105I1999 New York. NY r!I' D 2ND D D 2ND D D 3RD D D 3RD D D ~ D D ~ D D 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 mar( gestate. " '. 1/7 I /J~ 21. SIGNATURE OF GROOM. 22. SIGNATURI1- OF BRIDE. /JI'b~ ,K-p P? ~ -USE CURR?"JT NAME 23. DATE 071010003 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 New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY. D 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 COUNTY Olltcbess CITYITOWN Wappinger ~~~~~~T 1368 ~G~I~J~R 83 1. A. FULL NAME FIRST B BIRTH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL. SEE REVERSE) o SOCIAL SECURITY NUMBER ~28-5493 2. RESIDENCE A N V B. nllt~ (~ATEI ~--- C. CHECK ONE D CITY D TOWN ~ VILLAGE ~~~CIFY Weppingerw.l=eJls- o STREET ADDRESS 2833 \NeBt M8in street, UnitzlP 1~ E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? /if YES D NO 3. A. AGE 66 3B. DATE OF BIRTH M~ / ~ / 1~7 4. EMPLOYMENT A. USUAL OCCUPATION Retired B. TYPE OF INDUSTRY OR BUSINESS 5. PLACE OF BIRTH ~"r~RX.USA) 6. FATHER A NAME Samud Faligate B. COUNTRY OF BIRTH Italy 7. MOTHER A MAIDEN NAME T... Lanzano B. COUNTRY OF BIRTH It8Iy. 8. NUMBER OF THIS MARRIAGE :2 9. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT DEATH 001 B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) rY'DEATH C DATE LAST MARRIAGE ENDED? 04 / ?Q / 1aar\ MONTH D~ 1~ D. ARE ANY FORMER SPOUSE(S) ALIVE? D YES ~NO 10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION DATE OF DECREE PLACE ISSUED AGAINST WHOM (MONTH, DAY, YEAR) ICITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE ~^-. { SEAL } '-v-' I STATE FILE NUMBER (THIS SPACE FOR STATE USE ONLY) "I L 0 SUPPLEMENTAL FILE FROM THE BRIDE ~ 11. A. FULL NAME FIRST ~!,! Kapilevi~RRENT SURNAME B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Pereltsvayg c. SURNAME AFTER MARRIAGE I=lIIigate (OPTIONAL - SEE REVERSE)" D. SOCIAL SECURITY NUMBER 094-76-3064 12. RESIDENCE A. N 'tTATE) B. ~ C. CHECK ONE D CITY D TOWN IiiII' VILLAGE ~~~CIFY Wappingem I=Alkr. D. STREET ADDRESS 2833 \Nest Main street, Unit ZIP 1:2590 E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES D NO 13. A. AGE 45 13.8. DATE OF BIRTH ~H /~Y 1~ t4. EMPLOYMENT A. USUAL OCCUPATION Beautician B. TYPE OF INDUSTRY OR BUSINESS llps To Toes 15. PLACE OF BIRTH ~ ~ne 16. FATHER A. NAME AdaIde pereasvay:g B. COUNTRY OF BIRTH llkrelne 17. MOTHER A. MAIDEN NAME ~. Chemlk B. COUNTRY OF BIRTH Ukraine 18. NUMBER OF THIS MARRIAGE 2 19. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT DEATH 100 8. HOW DID LAST MARRIAGE END? (3) rY'DIVORCE (3) D ANNULMENT (2) D DEATH C. DATE LAST MARRIAGE ENDED? 10 / AA /1QQQ MONTH ~ ~ D. ARE ANY FORMER SPOUSE(S) ALIVE? cY'vES 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 TIME MONTH MONTH YEAR YEAR 10:50 AM 07 PM 08 02 200 30 2003 ZIP 1~VIL 28. PLACE WHERE MARRIAGE OCCURRED A. STATE NEW YORK B. COUNTY ~ C. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) / D CITY OF D TOWN OF 19""VILLAGE OF n RELIGIOUS OTHER, SPECIFY TITLE J~n~ SPECIFY 31. SIGNATURE.