080
.... f-
z :;:
w
r/)
w <
!Xl C
0
.... [L
=>
0
:J: U-
r/) <
z
0
~
a::
....
r/)
a
w
a::
w
Cl
<
a:
a::
<
::;;
IL
0
W
~
u
ii:
i=
a::
w
u
w
a::
w a:
~ w
!Xl
r/) ::l!
r/) =>
w z
a:: 0
0 ~
0
< tu
~ w
a:
i3 Ii;
W
D..
r/)
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jon F. SalmI
J co Dutchess
UNTY WCtppl
CITYrrOWN nger
.. DISTRICT 1 J66
NUMBER
REGISTER 80
NUMBER
1. A. FUll NAME
MIDDLE
CURRENT SURNAME
FIRST
D..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 051-72-3851
D. SOCIAL SECURI=V
2. RESIDENCE A. ark B. Dutchess
C. ~6CK ONE ~ ~i10WN 0 VILLAGE (COUNTY)
SPECIFY 658 811""'- ~
D. STREET ADDRESS ""'W'Ii' gu.... ZIP 1~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES D"NO
3. A. AGE Z1 3B. DATE OF BIRTH D3 / 02 / 1
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUST'; OR BU8f~i PPI~
5. PLACE OF ~.H own ntI
(CITY, STATElCOUNTRY IF NOT USA)
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
Karol Peter SalmI
POland
A. MAIDEN NAME lucille Marie Pelrazlello
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORlf CIVIL ANNUbMENT
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 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
o
o
o
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kimberly A straIev
MIDDLE CURRENT SURNAME
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Sakal
(OPTIONAl. SEE REVERSE) 121 1::"-0525
D. SOCIAL SECURITY NUMBER -.,.,.
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 'lit>WN 0 VILLAGE
~~CIFY East FlBhkill
D. STREET ADDRESS 18 Helin Road ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES 0 ~O
13.A. AGE 26 13.B.DATEOFBIRTH 10 / 13 /1976
MONTH DAY YEAR
14. EMPLOYMENT
Central Schoc
ork
A. NAME Thorn. H. straIev
B. COUNTRY OF BIRTH U S A
17. MOTHER
A. MAIDEN NAME Michelle Ruth H'-~
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
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
o
o
o
o
o
o
o
o
TIME
YEAR
AM
01:51>M
10 CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 'CI ,;;;. J.I.
C. LOCATION OF CEREMONY T ~
(CHECK ONE AND SPECIFY)
'fcITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY 13 G " c. o,...r .
NAME (PRINT)
SIGNATURE ~