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COUNTY Dutchess
CITYITOWN Waooinger
~~~~f~ 1368
~5~~J~R 142
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Edward J. Niemcvk
MIDDLE CURRENT SURNAME
I"
STATE ALE NUMBER
(THIS SPACE FOR STA TE USE ONL YI
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Cynthia Marie Hornbeck
MIDDLE CURRENT SURNAME
.J
1. A. FUll NAME
11. A. FUll NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 084 52 7155
D. SOCIAL SECURITY NUMBER --
2 RESIDENCE A. N Y B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinqer
D. STREETADDRESS 100 Dusty Trail
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Niemcyk
(OPTIONAL. SEE REVERSE) 216-19-8921
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. N Y B. Dutchess
(STATE)..J (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 100 Dusty Trail ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
11 /07 /1973
MONTH DAY YEAR
ZIP 12590
o YES ~ NO
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51.1.
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE?
3. A. AGE 32 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Auto Body Painter
B. TYPE OF INDUSTRY OR BUSINESS Vince's Autobody
5. PLACE OF BIRTH Beacon, New York
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Edwin Niemcyk
B. COUNTRY OF BIRTH USA
16. FATHER
A. NAME Nelson Hornbeck
B. COUNTRY OF BIRTH USA
13. A. AGE 28
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Waitress
B. TYPE OF INDUSTRY OR BUSINESS Perkins
15. PLACE OF BIRTH poughkeepsie, New York
(CITY, STATE/COUNTRY IF NOT USA)
17. MOTHER
A. MAIDEN NAME Patricia 0 'Brien
B. COUNTRY OF BIRTH USA
1
7. MOTHER
A. MAIDEN NAME Rose Risole
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
1B. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEaTH
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
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o 1ST 0 0
o 2ND 0 0
o 3RD 0 0
o ~H 0 0
belief that the information I provide is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ (\ - 1.. /I.- ~c...K.
.. ~SE CURRENT NAME 09/05/2002
DATE
21. SIGNATURE OF GROOM"
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of t bride and groom named above by any person authorized
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 only for the urpose of a second or.subsequenfceremony.. -
~ 24. TOWN OR CI fLEJ'lK J 25 A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRIN ~)fla. .
SEAL SIGNA'ii7"R DATE 09/05/2002 TIME MONTH
'-..,-I M~O~~bu appinger Falls, NY 12590 01:18~~ 09
STREET CITYIT WN TATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
by New York Domestic
1~IL
28. PLACE WHERE MARRIAGE OCCU~ _
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY
(CHECK ONE ANDYECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY
~I+PP, t\Jo1 v1;
NAME (PRINT)
SIGNATURE ~ ·
DOH.9B (11/98)
ZIP
31. WITNESS TO CEREMONY ~ .
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SIGNATURE~. C ~ 4