175
:J
p)
o
U)
N
.....
.lII:
....
~
w
~ ~
4) Iii
Z
lID
fij
!zi- ....
l}jGJ :;:
~ c:(
00) C
...J:} w-
~O ~ It
uu. - c:(
~ - i
~11I 0
a:t: ~
liitU _
a..JO
l:!G)
urc
~m
rn.
::;G)
~
~
[\0
i=
a:
w
()
w
a:
w
:x:
~
Ul
Ul
w
a:
o
o
..
~
(3
w
a.
Ul
z Z
~ Q W
l:! ~ ~
~ ~ 0
::; 5 u:
!z Ul _
.. u. I-
~ 0 a:
~ g? W
Iii C5 0
... '"
o
z ;;:;
COUNTyQutchess
CITYfTOWN Wappinger
~~J~kCRl'\ 368
~5~~J~R175
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Kenneth W. Wvskida
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
~ I~vla'o~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Rosemary C. Taylor
MIDDLE CURRENT SURNAME
.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
a.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Wvskida
(OPTIONAL. SEE REVERSE)051 no OO?6
D. SOCIAL SECURITY NUMBER -., - oJ
12. RESIDENCE ANew York B. Dutchess
(STATE) wi (COUNTY)
C. CHECK ONE 0 CITY [J TOWN 0 VILLAGE
~~~CIFYPoughkeepsie
STREET ADDRESS54 stephame Lane ZIP 12603
IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
/24 1973
DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEn53-66-3200
D. SOCIAL SECURITY NUMBER U U
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY'tJ TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
o. STREET AODRESS54 Stephanie Lane ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"[j NO
3. A. AGE30 3B.DATEOFBIRTH 10 /28 /1972
MONTH DAY YEAR
D.
E.
13. A. AGI,29 .
13.B. DATE OF BIRTH
02
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Un - Employed
15. PLACE OF BIRTHHereford, England
(CITY, STATElCOUNTRY IF NOT USA)
16. FATHER
A. NAMEA.lexander Taylor
B. COUNTRY OF BIRTJ;ngland
17. MOTHER
A. MAIDEN NAME Caroline Campbell
B. COUNTRY OF BIRT~imbabwe
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
4. EMPLOYMENT
A. USUAL OCCUPATION Mail Clerk
B. TYPE OF INDUSTRY OR BUSINESS U S Postal Service
5. PLACE OF BIRTHBronx, New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Walter Wvskida
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Judith Kousek
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. 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 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) A~ 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULeo.-'PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COl,lNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
eclare that no legal Impediment eXists
a:
w
III
::li
OJ
z
o
~
Iii
w
a:
Iii
1ST
2ND
3RD
4TH
I, being duly sworn, depose an sa
as to my right to enter into the m i
21. SIGNATURE OF GROOM ~
o
o
o
W
en
z
W
o
::i
23. ~~::T~~~DO~N,.oO~~06'~ ~~Bgr~i~E DATE 11/12/2002
This license authorizes the marriage in New York State person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within Ne York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the urpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Glo .
TIME MONTH
SEAL SIGNATURE ~ - DATE 11/12/2002
'-.-" M~'lfMfcfar~i,ush Rd er Falls NY 12590 11 :33 AM 11
, S R A IP PM
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
YEAR
TITLE
28. PLACE WHERE MARRIAGE OCCU~
A. ST.-. NEW YORK B. COU ~
.~.""
C. LOc,.;TIC:li-l OF CEREMONY
..::r;,.s'71~;::ctHECK ONE ANDYECIFY)
, ,)'-0 CITY OF ~OWN OF 0 VILLAGE OF
/~-7-~,.1, ~
JJ SPECIFY Dak.... ~t" s J..L,
_ ,,(Z~
ZIP
31. WITNESS TO CEREMONY
CIVIL
NAME (PRINT)
SIGNATURE ~
DOH-BB (11I9B)
NAME (PRINT)