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J COUNTY Dutchess
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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael Aleiandro Valerio
MIDDLE CURRENT SURNAME
FIRST
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Denise M. Lukavic
MIDDLE CURRENT SURNAME
1. A. FULL NAME
.11. A. FULL NAME
FIRST
"-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Lukavic - Valerio
(OPTIONAL. SEE REVERSE) 053-72 2773
D. SOCIAL SECURITY NUMBER -
12. RESIDENCE A. Connecticut B. Hartford
(STATE) J (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~CIFY Bristol
D. STREET ADDRESS 895 Matthew Street Unit 49ZlP 06010
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 "No
13. A. AGE 29 13.B. DATE OF BIRTH 10 / 09 /1973
MONTH DAY YEAR
'j
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 028-58-7139
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. Connecticut B. Hartford
(STATE) J_ (COUNTY)
C. CHECK ONE 0 CITY O...,.OWN 0 VILLAGE
~~~CIFY Bristol
D. STREET ADDRESS 895 Matthew Street Unit 4~IP 06010
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES o.fNO
07 / 19 / 197
MONTH DAY YEAR
14. EMPLOYMENT
3. A. AGE
26
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Construction
B. TYPE OF INDUSTRY OR BUSINESS Putnam Canstrudion
5. PLACE OF BIRTH MavaDUez. Puerto Rica
(CITY~IF NOT USA)
6. FATHER
A. NAME. Ambioris Valerio
B. COUNTRY OF BIRTH Dominician Republic
7. MOTHER
A. MAIDEN NAME FIi7RhAfh RndrigJliP.7
B. COUNTRY OF BIRTH Puerto Rico
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
A. USUAL OCCUPATION Retail Manaaer
B. TYPE OF INDUSTRY OR BUSINESS The Walkina Comoanv
15. PLACE OF BIRTH North Tarrvtown, New York
(CITY, STATE/COU~IF NOT USA)
16. FATHER
A. NAME John Lukavic
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME I ynn ~IJter
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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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 ANNUUED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATEICOUNTRY, 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
D
o
o
1ST
2ND
3RD
4TH
I, bBing uly sworn, depose an say, t
as to my right to enter into the ma .
21. SIGNATURE OF GROOM ..
o
o
o
~
{ SEAL }
'-.r-'
DATE
of the bride and groom named above by any person authorized by New York Domestic
ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
be used only for the urpose of a second or subse uent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
YEAR MONTH
YEAR
TIME
MONTH
AM
01 :2&n
05
13
20 3 07 11 2003
TR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCUR~
A. STATE NEW YORK B. COUNTY4l!J!lJ!1/1
C. LOCATION OF CEREMONY
(CHECK ONE AND ?IFY)
o CITY OF ~WN OF 0 VILLAGE OF
.
SPECIFY W."" IN'~
5;110
NAME (PRINT)
SIGNATURE" ·
DOH.98 (11/98)
NAME (PRINT)
SIGNATURE ..