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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.tfm..'J J. Lillis CURRENT SURNAME
1ST 0 1ST 0 0
2ND 0 2ND 0 0
3RD 0 3RD 0 0
4TH 0 4TH 0 0
I, being duly sworn, depose and say. that to the be belle that t e in ormation I provided is true and t at I declare that no legal impediment exists
as to my right to enter into the marriage state. .JA I ~
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~ tlttitti .Jf.,.ilfe{,
(/ USE CURREif[ NAME
23. ~~;fr~~~Do~N~~~~~ 6(il~':f~~~E DATE 111:.10"00'
This license authDrizes the marriage te of the bride and groDm named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies with New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o 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
couN"@utche~s
CITYfTowWappinger
DISTRIfO.T"GO
. NUMBElI... '"
~5~~J~S1
1. A. FULl NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 130 62 6099
2. RESIDENCE N~~mp€nire B.C~lY)
C. CHECK ONE 0 cn", 0 TOWN 0 VILLAGE
AND
SPECIPNorth COnV!ay
D. STREET ADDRElfRR1 Box 335 E Z1lft?R6n
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 Yr!t!' 0 NO
IJ~ 1~AY -1~
3. A. AG38
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATIO'inn keeper
B. TYPE OF INDUSTRY OR BUSINESRare Bare
5. PLACE OF BIRtW..lW1Poo~w, ~Pm)
6. FATHER .
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A. NAMEJameE Lillie
B. COUNTRY OF BIRTU 5: A
7. MOTHER
A. MAIDEN NAME Bridget Maguir:e
B. COUNTRY OF BIRT1mlaoo
8. NUMBER OF THIS MARRIAGE'I
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIYORCE CIVIL ANNULMENT
g g
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
DEATH
(3) 0 ANNUlMENT
/ /
MONTH OAY 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
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{ SEAL}
'-v-I .
NAME (PRINT)
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
lR,\\c'O'h
~
(}tt
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
AIir.iR KRta~8 Kufel
J MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGd iIIi~
(OPTIONAL - SEE REVERj]
D. SOCIAL SECURITY NUMBER n 1-R7 -7966
12. RESIDENCE""P-W ~mp~hirp- CartQl
(S) (ONTY)
C. CHECK ONE 0 clnY'tJ TOWN 0 VILLAGE
AND
sPEclltJnrth r.n"w~
D. STREET ADDRERR1... Box 335 E
zQ3860
o YEr'D NO
1977
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGlS 13.8. DATE OF BIRTH 02 t1
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATIO,,"," Kp.p.per
B. TYPE OF INDUSTRY OR BUSINESRed Apple inn
15. PLACE OF BIRrW~~~t~u~~~~~~SA)
16. FATHER
A. NAMAndrz~j Knfp.1
B. COUNTRY OF BIR~nr8nd
17. MOTHER '
A. MAIDEN NAMEwa Przybyl
B. COUNTRY OF BIR'PO'S"ld
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
TIME
MONTH
YEAR
MONTH
YEAR
AM
PM 11
2002 01
19 2003
21
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME 1.10, DAY Y R 0 ~IGIOUS
/:L /3 ,;(OOi!. 9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRE~
A. STATE NEW YORK B. COUN~~5
1i;g~~~am Fa GNxe"oc,p-
SIGNATURE ~
MAILING ADDRESS
M(~l-lf.\-€L
TITLE
DATE
1\ tLI N'lO 1\1 So T
STREET
30. WITNESS TO 9E
NAME (PRINT)
SIGNATURE ~
DOH.9B (11/98)
t.vA-PPIN~GI2S P~LL~
CITYfTOWN
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY WfiPf' ;,v692S hiU5
NY
STATE