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COUNTY Dutchess
CITYfTOWN Wappinger
~~J::f:1368 '
~5~~J~R17
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mi~h~p.1 .John Dotoratos
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sanela Kopic
MIDDLE CURRENT SURNAME
.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
ll.
F;j
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE!.
D. SOCIAL SECURITY NUMBER 1 26-66-9435
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOW~ VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 50 South Remsen ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? otJ YES 0 NO
04 /07 /1983
MONTH DAY YEAR
05
13. A. AGf27
3B. DATE OF BIRTH
3. A. AGE26
3B. DATE OF BIRTH
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATlo~tay At Home Mom
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRT~rcko, Yugoslavia
(CITY. STATE / COUNTRY IF NOT USA)
4. EMPLOYMENT
A. USUAL OCCUPATION Polir.p. Offi~er
B. TYPE OF INDUSTRY OR BUSINESS Law Enforcement
5. PLACE OF BIRTHManhattan, Nv
{CITY. BTATE / COUNTRY1F NOT USA)
6. FATHER
A. NAME .Iohn I notor::lto~
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Christine Louie
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
16. FATHER
A. NAMeQraao Kopic
'B. COUNTRY OF BIRT~Ugoslavia
17. MOTHER
A. MAIDEN NAMEZe1jka Filipovic
B. COUNTRY OF BIRTtYUgoslavia
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. '.~ YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
"
20. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATElCOUNTRY. IF NOT USA) SELF SPOUSE
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 ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (CITY/COUNTY. STATEICOUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
legal Impediment exists
o
o
o
o
o
o
1ST
2ND
3RD
USE CU
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK.
This license authorizes the marriage in New York State of the 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 purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
by New York Domestic
~
{ SEAL }
'-v-'
YEAR
MONTH
YEAR
NAME (PRINT)
TIME
MONTH
DATE 03/15/2010
ers Falls NY 12590
WN STATE ZIP
27. TYPE OF CEREMONY
OJit RELIGIOUS
9 0 OTHER, SPECIFY
A. STATE NEW YORK B. COUNTY ()r7V'5 g
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF)O TOWN OF 0 VILLAGE OF
SPECIFY IJ -;" / W I YvlS ...v-
AM
02:03 PM 03
16
2010
05
14 2010
in
ITY
26. SOLEMNIZATION OCCURRED
TIM MO. AY YEAR
26. PLACE WHERE MARRIAGE OCCURRED
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10 CIVIL
29. OFFICIANT ~ 11 S.L. 11
NAME (PRINT) 'oJ "f""rl /I A.J? 1:7-. '"lei<.. L-
SIGNATURE. 6~~~
MAILING ADD~
/ ~ 3 ~ ~ fl.d' Ifl..A,., ll--..DhLc /c-
STREET CITYITOWN""'"
3D. WITNESS TO C~ MONY
NAME (PRINT)
SIGNATURE.
TITLE 1C.".oI.--"~/\eII'
DATE JjcJ 7/14
fV-1
STATE
"...,.\11....,.. '^,.."'^...~\
NAME (PRINT)
SIGNATURE.