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COUNT"Qutchess
CITY 'TOWN Wappinger
~~~~kCRl'\ 368
~G~'€~~P61
~ I A I t:. Ut' Nt:W YUHI\.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael R. Helffrich
CURRENT SURNAME
(THIS SPACE FOR S I A Ie U::,c UIVL r)
lt~t
17' ~ /l
~.~ -OX
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Joanne Davis
II A
FULL NAME
A FULL NAME
FIRST MIDDLE
BIRTH NAME (MAIDEN NAME). IF DIFFERENT Hornyak
C SURNAME AFTER MARRIAGE He\ffrich
(OPTIONAL. SEE REVERSEl.t 22 54 5230
D SOCIAL SECURITY NUMBER I - -
12 RESIDENCE ANew BDutchess
C CHECK ONE (STA~) CITY ~ TOWN 0 VILLAGE (COUNTY)
~~~ClFyWappinQer
D STREET ADDRESJ Sciibo Road
zlPY ork
o YES'tJ NO
1971
YEAR
FIRST
MIDDLE
CURRENT SURNAME
BIRTH NAME IF DIFFERENT
3 A
AGJ5
04
MONTH
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13 A. AGE31 13.B DATE OF BIRTH 02 ,,02
MONTH DAY
3B. DATE OF BIRTH
14. EMPLOYMENT
A USUAL OCCUPATIONSocial Worker
B TYPE OF INDUSTRY OR BUSINESSSaint Basil Academy
15 PLACE OF BIRT~eekskill, New York
(CITY. STATE'COUNTRY IF NOT USA)
16. FATHER
A NAMJleter Hornvak
B. COUNTRY OF BIRTU S A
4. EMPLOYMENT
A. USUAL OCCUPATION Correctional Officer
B. TYPE OF INDUSTRY OR BUSINESSOepartment Of Correction
5. PLACE OF BIRT~reenwich. Connecticut
(CITY, STATE/COUNTRY IF NOT USA)
6 FATHER
A. NAME Robert Helffrich
B COUNTRY OF BIRTHU S A
17. MOTHER
A MAIDEN NAMERn~p.mHry Ryhp.1
B COUNTRY OF BIRTU S A
18 NUMBER OF THIS MARRIAGE 2
7. MOTHER
A MAIDEN NAME Edite Kalnins
B COUNTRY OF BIRTH Latvia
8 NUMBER OF THIS MARRIAGE2
w
en
z
w
()
:J
19 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B HOW DID LAST MARRIAGE END? d'D DIVORCE (3) D ANNULMENT (2) D DEATH B. HOW DID LAST MARRIAGE END? (3)'6 DIVORCE (3) D ANNULMENT (2) D DEATH
C DATE LAST MARRIAGE ENDED? 04 /28 /1994 C DATE LAST MARRIAGE ENDED? 08 /11 /2000
MONIjI DAY YEAR MON-ru. DAY YEAR
o ARE ANY FORMER SPOUSE(S) ALIVE? 1] YES D NO 0 ARE ANY FORMER SPOUSE(S) ALIVE? TI YES D NO
10 IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION 20 IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY. YEAR) (CITY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
15T04/28/1994 White Plains, New York c -6 15TOBf111200n pOlJghkeep~ip.. New Ynrk ~ D
2ND [] D 2ND [J D
3RD D D 3RD 0 D
4TH D D 4TH D C
I, being duly sworn, depose and say, that to the best of my knowled elief that the information 1 provided is true and that I declare that no legal impediment exists
as to my right to enter into the marri st . - ~ ~ .
21 SIGNATURE OF GROOM ~ 22 SIGNATURE OF BRIDE ~ /1,1'::- ~1AN
USE CURRENT NAME
23 ~~JfT~~~D~N1o~O~~ ~1~:g~~~~E DATE 05/1112002
This license authorizes the marriage in New York Stat of the bride and groom named above by any person authorized by New York Domestic
Relations Law S11 to perlorm marriage ceremonies within York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
[J 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
{ } NAME (PRINT) G_IO . . M
, A TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ ~ k DATJ)5/11/2002
'-y-I ~b'~fa~~1iush Rd in er Falls NY 12590
STREET CITY/TOWN STATE
~~~R~~~Ri~~~ 'O~O~~~N~zEE~ 26 SOLEMNIZATION OCCURRED 27 TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO DAY YEAR o)? RELIGIOUS
DATE AND AT THE TIME AND N*
PLACE INDICATED )', 30 PM 6 b 02.. 9 D OTHER, SPECIFY
~~~t~~~~m A y 1LVl(1 P Be ec n.l yi:; - kb 'utA TITLE .pei ~ ,J-uy
SIGNATURE ~ n tlko. (J. ~(JUJ. & - IJcd DATE Co \2-i \ i) 2-
MAILING ADDR~ / _ '
dO Aro (J. d- L\t. t- lS h lu..li Ny'
STREET CITYITOWN S~TE
30. WITNESS TO CEREMONY
NAME (PRINT) <'\. \ <:::-\r-..lL. \ \ ~
SIGNATURE ~ << '
DOH.98 (11/98)
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
o
DEATH
o
YEAR
0:10 ~~ 05
18
2002 01
16 2002
ZIP
2B PLACE WHERE MAP,RIAGE OCCURRED
I D CIVIL
A. STATE NEW YORK B COUNTY Dc }.\r-L 5c
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
Id- '{.2..y
ZIP
31 WITNESS TO CEREMONY
D CITY OF C TOWN OF ~ VILLAGE OF
SPECIFY fA )CLP,o I ~.....~ da Ih
SIGNATURE ~
NAME (PRINT)
(