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1 . A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert Francis Jedlicka" Jr
FIRST MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL YI
I
COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~~ 1368 .
~5~1:~~R 71
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sara Elizabeth Von Burg
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Von Buro-Jedlicka
(OPTIONAL' SEE REVERSE11 0-74-1286
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BPutchess
(STATE) (COUN1Y)
C. CHECK ONE 0 CITY 0 TOW~ VILLAGE
~~~CIFYWappingers Falls
D. STREET ADDRES~.,7 Mill Street; Apt 1
ZIP 12590
.....0 YES 0 NO
)982
YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE),.,31 51 6145
D. SOCIAL SECURITY NUMBER L. - -
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN'iO VILLAGE
~~~CIFY Waooinoers Falls
D. STREET ADDRESS 27 Mill Street; Apt 1 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
06 /26 /1984
MONTH DAY YEAR
3. A. AGE 26
3B. DATE OF BIRTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE28 3B. DATE OF BIRTH 04 ..0'1
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINEssEducation
15. PLACE OF BIRTHPOughkeepsie, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEHugo Roland Von Burg
'B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAME Brenda Lorraine Diehl
B. COUNTRY OF BIRT~ S A
16. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
4. EMPLOYMENT
A. USUAL OCCUPATION Substitute Teacher
B. TYPE OF INDUSTRY OR BUSINESS Education
5. PLACE OF BIRTH Brunswick, Me
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Robert Francis Jedlicka Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Cecelia Jean Malina
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 03 / 03 / 2010 '
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
03/03/2010 Onslow, North Carolina r!5
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
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. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
o
o
o
o
o
o
US
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEF RE M
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
n
by New York Domestic
r-^-.
} NAME (PRINn
{SEAL SIGNATURE ~
MA~~GICfft
'-.t-I STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
MONTH
YEAR
YEAR
TIME
MONTH
11:00AM 06
PM
27 2010
29
2010
08
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT~.TChSS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF wVILLAGE OF
SPECIFY W/fIJ{ltfI$'C5 F/tU-S
29. OFFICIANT
NAME (PRINn
If,e. fJRIE's-r
7/.7. 3/ld
(
NAME (PRINn
SIGNATURE~
DOH-9B (0312006)
NAME (PRINn
SIGNATURE~