136
tI.
N
+
....
Z
w
(/)
w
'"
0
...J
~
0
J:
(/)
Z
O'
;::
~
....
(/)
a
w
a:
w
"
<(
or
a:
<(
::;
u.
0
w
....
<(
u
Ii:
;::
a:
w
u
w
a:
w
J:
;:
(/)
(/)
w
a:
0
0
<(
~
u
W
tI.
(/)
W
en
z
w
0
::l
+
Z' .
a:J:Z W
~t:0
tu;:;:: ~
a:"rs <C
tii~~ 0
~UW
::;,,5 u::
....Z(/) t=
z-
o~~ a:
[OU) w
0....>- 0
w~~
bffi"'
z~;;:;
1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST r.hri~tor~M.~ M~tthp."\~~a'?J~.Q.E
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
I
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~; 1368 .
~E~~~~R 136
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Megan Elizabeth Cholowskv
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 067 -66-044 7
2. RESIDENCE A. NY B. nllt~hp.~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY ~rplngAr
D STREET ADDRESS 39 Fieldstone Blvd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS DF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 29 3B. DATE OF BIRTH MO~~ / DQ7 / Yt~81
4. EMPLOYMENT
A. USUAL OCCUPATION Pcck~op. np.livp.ry
B. TYPE OF INDUSTRY OR BUSINESS FAd Ex
5. PLACE OF BIRTH Kinaston, NAW York
(CITY. '!iTA TE / COUNTRY IF NOT USA)
6. FATHER
A. NAME leffrey I ynn H~rtm~n
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME KathlAAn Ann Donahue
B. COUNTRY OF BIRTH LJ S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Hartm~n
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 00-74-2844
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY appmger
D STREET ADDRESS 39 Fieldstone Blvd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
Al6 A 985
DAY YEAR
13. A. AGE ?~
13B.DATE OF BIRTH
06
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Stay At Home Mom
B. TYPE OF INDUSTRY OR BUSINESS Homecare
15. PLACE OF BIRTH Yonkers. New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME John Konrad Cholowsky
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Coleen Maria Carey
B. COUNTRY OF BIRTH USA
lB. 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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES
DAY
ONO
YEAR
YEAR
MONTH DAY
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, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
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 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm. depose and say, that to the best of my knowledge and belief that the information I provided is true
as to my right to enter into the marr ge state. ~~
21. SIGNATURE OF GROOM~ / ~ 22. SIGNATURE OF BRIDE~
USE CU
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
o 0
o 0
o 0
o 0
I impediment exists
DATE
by New York Domestic
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~llto pertorm 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
{ } NAME (PRINT) Joh C. Mast rson
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE 10/04/201
"'-- -..J MAIIJ.I'W ~q~IIFlE~Se AM
-v- :lU M CCI sh Rd, Wappingers Falls, NY 12590 12:26PM 10
STREET CITYITOWN STATE ZIP
~~~R~~~RT:~~ IO~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR O-r:('RELIGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. ~. (/0 I () I 0 i 0 9 0 OTHER. SPECIFY
MONTH
YEAR
12
03 2010
05
2010
2B. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY Ou~.i"..Q ~
29. OFFICIANT
NAME (PRINT)
1C~. '~. ~ IMetJ
~~
S +-_ (i.~ ((....l~
CITYfTOWN
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 8"'fOWN OF 0 VILLAGE OF
SPECIFY W 0. \P ~ l ^ f c;pj
t2e"~
\D116
tZlJ. ,
TITLE
DATE~
SIGNATURE ~
MAILING ADDRESS
22 S
STREET
30. WITNESS TO CEREMONY
NAME (PRINT) S-\- ~
~
SIGNATURE~
DOH-98 (09/2009)
STATE
NAME (PRINT)
SIGNATURE~