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Dutchess
COUNTY W .
tlpplflger
CITYiTO~1I!I
DISTRICT I ",,68
~~~I~~~R 19
NUMBER
::) I A I t: Ut" Nt: VV Y UHI\.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOMrI
Kevin J. Hu ey
(THIS SPACE FOR STA TE USE ONL Y)
~l(;
J'l6-tJj{
~
L D SUPPLEMENTAL FILE
A FULL NAME
FROM THE BRIDE
Inna V. Miroutenko
MIk'~E CURRENT SURNAME
Mlroutenko
B BIRTH NAME (MAIDEN NAME), ~JH~ENT
C SURNAME AFTER MARRIAGE Y
(OPTIONAL. SEE REVERSE)'122-86-6624
o SOCIAL S~~RITY NV~BEfL
New YOrK uutchess
12 RESIDENCE A. 1ST ATE)" B (COUNTY)
C CHECK ~ D. ~LTY 0 TOWN 0 VILLAGE
AND YVapplm~er
SPECIFY -
19E Pembroke Circle 12590
D. STREET ADDRESS ZIP
"
E IS RE~~NCE WITHIN LIMITS OF CITY OR INCORPORA TEa lLAGE:,e9 0 Y}tf1:fO
13 A. AGE 13.B. OATE OF BIRTH --
MONTH DAY YEAR
11. A FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
B BIRTH NAME, IF DIFFERENT
c s~~~~~JN~LTE~~:~~e~~sEl)87 -60-6278
o SOCIAL SE\;'Uj1ITY NW4BElJ.a. uut n
New YO,!'.. cess
2. RESIDENCE A. (STATE),J B. (COUNTY)
C CHECK O~, ..G-~LY 0 TOWN 0 VILLAGE
AND yvapp'f1~er
SPECIFY 19E Pembroke Circle
o STREET ADDRESS ZIP
.,.
E IS RE~9fNCE WITHiN LIMITS OF CITY OR INCORPORATED1V~LAGE? .il2D YES ~gco
3 A. AGE 3B. DATE OF BIRTH ~ ~
MONTH DAY YEAR
4 EMPLOYMENT M
w.~mager
A. USUAL OCCUPATION I P M U I
"'. " c l1a e
B TYPE OF INDIJSTRY OflIBUSIt-I~SS to.
LOWVII e New yorn.
5. PLACE OF BIRTH '
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER D Id H rI
ona u ey
A NAME U 5 A
8. COUNTRY OF BIRTH
12590d
14. EMPLOYMENT
B TYPE OF IND~TRY OR BU~NES1.Jk
15. PLACE OF BIRTH aporoz Ie, ralne
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER VI d" " M" ut k
A NAM a Imlr Iro en 0
B COU:TRY OF BIRTiaporozhle, UfCralne
17. MOTHER "
A. MAIDEN NAME Lansa Lucenko
8. COUNTRY OF BIRT.?apo~oZhie, UkraIne
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI~ORCE CIVIL A~ULMENT
DltTH
7. MOTHER
A. MAIDEN NAME Elaine Balash
USA
B. COUNTRY OF BIRTH 2
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~RCE CIVIL A~ULMENT
DltTH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVO'(ja (3) 1 ~NULMENT 19~9 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVOlf.2 (31lU.NNULMEN20d~ DEATH
C. DATE LAST MARRIAGE ENDED? _~ / / C. DATE LAST MARRIAGE ENDED? / /
MON IV DAY YEAR MONT" DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 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
1 ST ~ff2fi99~Rt:artnel:~evtV~rk NOT USA) S~F SPO~E 1 ST Om~bO~RRotklflndElCOouTntY: ~ewA) S~ SPO~E
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
nowledge and belief that the information I provided is t~ I declare ~hat no legal impediment exists
2 SIGNATURE OF BRIDE ~ .0Z1~
USE CURRENT NAME 03/05/2002
DATE
21.
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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
Relations Law S11 to perform marriage ceremonies within N 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 C(;16fi~K J" Morse 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
MONTH
by New York Domestic
,-I'-.,
{ SEAL }
~
ZIP
2002 05
04 2002
YEAR
YEAR
03/05/2002
DATE
al S, NY 12590
STATE
27. TYPE OF CEREMONY
SIGNATURE ~
M2Er
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNT;/);'cfl-;;:::'S;'
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF I;l'( TOWN OF ::::J VILLAGE OF
SPECIFY II) A-P ~ /;..j &e{(..;
o 0 RELIGIOUS
9 0 OTHER. SPECIFY
l~CIVIL
29 OFFICIANT
NAME (PRINT)
TITJ;/VliFC boV \M;rcK#..2-;
NAME (PRINT)
SIGNATURE ~