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CCUN-!"V Dutchess
CITYITOWN Wa~pingef
~~J:kcFi 1368
~G~I:J~R 193
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Karma Gurmev
MIDDLE cuRiIENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
aPlt
I~' '10 /O~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Alexandra C. Strelka
MIDDLE CURRENT SURNAME
. 1. A. FUll NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. (~marle
o VILLAGE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Strelka
(OPTIONAL - SEE REVERSE) 052 60-2559
D. SOCIAL SECURITY NUMBER -
12. RESIDENCE A. \fs\wJl~~8 B. ~~~~arle
C. CHECK ONE 0 "CITY 0 TOWN 0 VILLAGE
~~~CIFY Charlottesville
D. STREET ADDRESS ! 000 Ivy Creek Drive
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE?
13. A. AGE~ 13.B. DATE OF BIRTH n~ /
MONTH
14. EMPLOYMENT
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL- SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. l{Jm)inia
c. CHECK ONE 0 ~ITY 0 TOWN
~~CIFY Charlottesville
D. STREET ADDRESS moo Ivy Creek Drive ZIP 22901
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 "rEs 0 NO
3. A. AGE 2~ 3B. DATE OF BIRTH ~ 2/ DA95 / YEA\91'
ZIP 22901
o 'fES 0 NO
1!i /19f\R
DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Fund Raiser
r B. TYPE OF INDUSTRY OR BUSINESS N Y E M A PrQjects Inc.
15. PLACE OF BIRTH Bellefont~Pennsyfvania
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Joseph Strelka
B. COUNTRY OF BIRTH Austria
17. MOTHER
A. MAIDEN NAME Bngifte VO"RlPf
B. COUNTRY OF BIRTH Austria
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
~
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c:(
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...Ju..
-c:(
A. USUAL OCCUPATION Translator
B. TYPE OF INDUSTRY OR BUSINESS "amr.henling Retreat Cent
5. PLACE OF BIRTH ~hillnnn Meohalaya
(CITY, STATE/C1iim'RY IFiiIOT USA)
6. FATHER
A. NAME Dupgyal Lama
B. COUNTRY OF BIRTH Nangr.hen
7. MOTHER
A. MAIDEN NAME Pema OoSma
B. COUNTRY OF BIRTH Nangr.hAn
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
DEATH
o
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?
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
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
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
0:
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o 1ST
o 2ND
o 3RD
o 4TH
elief that the information I provide
o 0
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o 0
o
ent exists
USE CURRENT NAME
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23. SUBSCRIBED AND SWORN TO BEFORE ME 12/23/2002
SIGNATURE OF TOWN OR CITY CLERK ~ DATE - --
This license authorizes the marriage in New York Sta any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used only for the ur ose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-v-'
YEAR
MONTH
YEAR
TIME
MONTH
10 :(J!1
PM
20 2 02
21 2003
12
24
ATE
27. TYPE OF CEREMONY
o)l[ RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY..])u'k~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VilLAGE OF
SPECIFY ~i 1/1 ~p .v~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE ANO AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
SIGNATURE ~
DOH.98 (11/98)