147
COUNTY
CITYITOWN
DISTRICT
NUMBER
REGISTER
NUMBER
OLJtche!=i!=i
Wappinger
1~nR
147
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
II I~tin K 8\1nek:
MIDDLE 1 'CURRENT SURNAME
:::i I A I t:. r-ILt:. NUMtU:."
(THIS SPACE FOR STA TE USE ONL Y)
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sereh A Wa'>L
MIDDLE cURRENT SURNAME
~
A FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N B BIRTH NAME. IF DIFFERENT B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE C SURNAME AFTER MARRIAGE Svpek
(OPTIONAL. SEE REVERSE) (OPTIONAL. SEE REVERSE) .,
D SOCIAL SECURITY NUMBER 127 -62-4503 SOCIAL SECURITY NUMBER 081-66-9187
2 RESIDENCE A. N v B nlltr.t'lp~!=: 12 RESIDENCE A ~ V B nllt,..hp~~
(ST;!;TE) ~U~) (STATE)' '(cc\J!)'fYi
C CHECK ONE 0 CITY oIrOWN 0 VILLAGE C. CHECK ONE 0 CITY 0 IotOWN 0 VILLAGE
AND W . AND W .
SPECIFY appmger SPECIFY applnger
o STREET ADDRESS 15 G Alpine Drive ZIP 12590 0 STREET ADDRESS 15 G Alpine Drive ZIP 12590
IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES [JoI'NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES [JoI'NO
3 A AGE 22 38 DATE OF BIRTH MON.Q9/ 098 / YEAt97 13. A AGE 21 13.B. DATE OF BIRTH MO~'iI / Jip / t~O
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4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION G~st'lier
B. TYPE OF INDUSTRY OR BUSINESS Rite - Aide
15. PLACE OF BIRTH (~Tc;.IJfln~~~R~li~bT~~:'^' York
16. FATHER
A. NAME Willi~m Way
B. COUNTRY OF BIRTH I J !:; A
17. MOTHER
A. MAIDEN NAME Sheila Blair
8 COUNTRY OF BIRTH I J !:; A
18. NUMBER OF THIS MARRIAGE 1
19 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
A USUAL OCCUPATION r.nmplltpr Prnor~mmpr
B TYPE OF INDUSTRY OR BUSINESS Unemployed
5 PLACE OF BIRTH
6. FATHER
(CITY. STATE/COUNTRY IF NOT USA)
A. NAME T erl !:;ypek
B. COUNTRY OF BIRTH Polanrl
7. MOTHER
A MAIDEN NAME Debbie Holt
B. COUNTRY OF BIRTH [J!:; A
8 NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
(1 0
DEATH
o
(2) 0 DEATH
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
13) 0 ANNULMENT
/ /
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
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
o
o
o
1ST
2ND
3RD
o
o
o
o
o
o
21
23. SUBSCRIBED AND SWORN T BE RE ME
SIGNATURE OF TOWN OR CI CL RK ~
This license authorizes the marriage in New York Sta e of the bride and groom named above by any person authorized
Relations Law 911 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 purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE
by New York Domestic
~
{ SEAL}
~
YEAR
MONTH
YEAR
NAME (PRINT)
TIME
MONTH
28 2001
10
30
20 1 12
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF TOWN OF rsI VILLAGE OF
II
SPECIFY