114
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REGISTER
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114
~ fAtE OF NEW 'fUHK.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
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L C SUPPLEMENTAL FILE
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/ FROM THE GROOM FROM THE BRIDE
A. FULL NAME Jeffrey Paul Budryk 11 A. FULL NAME Toshiko Koike
1.
FIRST MIDDLE CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
- B. BIRTH NAME. IF DIFFERENT B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE Koike
(OPTIONAL - SEE REVERSE) 150-54-9155 (OPTIONAL - SEE REVERSE) n/a
D. SOCIAL SECURITY NUMBER O. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B. Dutchess 12. RESIDENCE A. New York B. Dutchess
ISTATEI ICOUNTYI (STATE) " COUNTY)
C. CHECK ONE :: CITY Ki TOWN 0 VILLAGE C. CHECK ONE o CITY ~ TOWN = VILLAGE
AND Wappin~er AND Wappin~er
SPECIFY SPECIFY
D STREET ADDRESS 13 Montfort Woods Rd. ZIP 12590 D. STREET ADDRESS 13 Montfort Woods Rd. ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? - YES X: NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Xi NO
-
3. A. AGE 28 3B. DATE OF BIRTH April / 14 / 1972 13. A. AGE 36 13.B. DATE OF BIRTH Aug. /12 / 1963
MONTH DAY YEAR MONTH DAY YEAR
4. EMPLOYMENT 14. EMPLOYMENT
A. USUAL OCCUPATION Teacher A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS School in Japan B. TYPE OF INDUSTRY OR BUSINESS School in Japan
5. PLACE OF BIRTH Long Branch, New Jersey 15. PLACE OF BIRTH Agatsuma, Japan
ICITY. STATE/COUNTRY IF NOT USA) (CITY, STATEiCOUNTRY IF ';OT USAI
6. FATHER 16. FATHER
to- A. NAME Raymond Budryk A. NAME Satoshi Koike
:> B. COUNTRY OF BIRTH USA B. COUNTRY OF BIRTH Japan
c(
Q 7. MOTHER 17. MOTHER
u: A. MAIDEN NAME Judith Reimesch A. MAIDEN NAME So,no Karasawa
u. USA Japan
c( B. COUNTRY OF BIRTH B. COUNTRY OF BIRTH
B. NUMBER OF THIS MARRIAGE First lB. NUMBER OF THIS MARRIAGE First
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL .~NNULMENT DEATH
B. HOW DID LAST MARRIAGE END? 3\ = DIVORCE (3) 0 ANNULMENT :2! = OEATH B. HOW DID LAST MARRIAGE END? 13) = OlvCRCE 31 = ANNULMENT 2\ = ~E.~~:---
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR MONTH JAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES CJ NO D. ARE ANY FORMER SPOUSE(S) ALIVE? = YES = NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. 'F PREVIOUSLY DIVORCED OR ANNULED ~ROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE JF DECREE PLACE 'SSUED AGAINST WHOM
I,MONTH. DAY. YEAR) ,CITY. STATE COUNTRY, IF NOT USA) SELF SPOUSE (MONTH. DAY. YEAR) (CITY, STATECOUNTRY. IF NOT USAI SELF SPOUSE
1ST - - 1ST - -
- - ~ -
2ND - - 2ND - -
- - - -
3RD - - 3RD - -
-' - - -
.. - - 4TH "'"1 -
- -
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~--~ ~~~~~:" ~::.r1. '''''''/'' ,he ".~"'" I p',,'''' " '7~ '2 Z' ... J2.'~'m;-m." "".
" 'QRENT NAME ~
_ DATE July 21, 2000
_ ",arriage in New York ate of the bride and groom named above by any person authorized by New York Domestic
.v flt!rform marriage ceremonies within New 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 RKE1. 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) a~ne
25. B. SOLEMNIZATION PERiOD
ENDS AT MIDNIGHT ON
J}~ 17'"
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TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
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SIGNATURE ~
MAILING ADDRESS.
PO Box :124, Wa
S E
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
IP
11 : 15AM
PM
7
22
00
9
19
00
1 = CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY DcAJ....~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ::nbWN OF 0 VIlLAGE OF
SPECIFY ~t ilt~ l~ ~ \ \
NAME (PRINT)
SIGNATURE ~
DOH-9B (1198)
SIGNATURE ~