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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.
