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:I {,QUNTY
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
AI~\'~RNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
CITYfTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
Outcbe:>>
Wappinger
1368
72
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~li.lj~SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
0..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
O. SOCIAL SECURITY NUMBER
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c. S~~~:tMr~~rt~~e~~SE) '*-'ayBheRker
D. SOCIAL SECURITY NUMBER 587 ...Ug...5Ci!&
12. RESIDENCE A. .,Var:k B. QMl~8B1
C. CHECK ONE 0 CITY 0 ~WN 0 VILLAGE
AND 'Na'.
SPECIFY 11 pplAg8I'
D. STREET ADDRESS 15 A CIRteItlury Lln. ZIP 12580
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 'fIA0
13. A. AGE 26 13.B. DATE OF BIRTH oo.A2 / . / 1Q11
14. EMPLOYMENT
A. USUAL OCCUPATION 8tHdeRt
B. TYPE OF INDUSTRY OR BUSINESS Dutch_I Community
15. PLACE OF BIRTH (l.T~EItd:~,
16. FATHER
A. NAME
26&-73-11107
_Vade B. (~_I
o CITY 0 rIOWN 0 VILLAGE
WappingeAI
D. STREET ADDRESS 15 A Clntemerry Lane
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3B. DATE OF BIRTH
2. RESIDENCE A.
C. CHECK ONE
AND
SPECIFY
ZIP 12580
o YES D~O
3. A. AGE 49
4. EMPLOYMENT
MO
to-
:;
<C
C
i!
LL
<C
A. USUAL OCCUPATION IiR;iR..
B. TYPE OF INDUSTRY OR BUSINESS I. S. M.
5. PLACE OF BIRTH ~"MTI.IIA)
6. FATHER
A. NAME P8l8r V.h8Rk8r
B. COUNTRY OF BIRTH Rt_.
7. MOTHER
A. MAIDEN NAME MIl'll BondIrylMkllyI
B. COUNTRY OF BIRTH RUSlII
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
ARabIIi LjIIhh
B. COUNTRY OF BIRTH Ukrllne
17. MOTHER
A. MAIDEN NAME Tltlne PoIjeI<<wl
B. COUNTRY OF BIRTH R\ISISII
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
100
B. HOW DID LAST MARRIAGE END? (3) 0 wl\tORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? ~ "" / ~
MONTH DAV-- YI!IlR""--
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 _S 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
000
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH D~ 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
05fa'2003 PoughIMpsI.. New Yerk
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o 1ST 0 0
o 2ND 0 0
o ~D 0 0
o 4TH 0 0
be lef that the In ormation provided IS true and that I ec are t at no legal impediment exists
NATURE OF BRIDE ~ aI/Iu:l:J../o~"Q ~f:>'~~
USECURRENTNA~
DATE
This license authorizes the marriage in New York St e 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.
o If checked. this license is to be used onl for the pu ose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL }
'-v-I
TE
YEAR
NAME (PRINT)
SIGNATURE ~-
MAILING ADDRESS
TIME
MONTH
YEAR
MONTH
AM
08
17
08
15 2003
STRE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICAT
IP
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT;j),<rr~
C. LOCATION OF CEREMONY
(CHECK ONE AN~IFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY ~"'-b If JC-z..-r ~) ~
ZIP
31. WITNESS TO CE~MONY .
NAME (PRIN~ :>e ~ lJ
SIGNATURE ~. ~
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