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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
laralJQhn ZrodIQ~SURNAME
COUNTY nlltr.hp.~~
CITYiTOWN W~ppinop.r
~~~:~~ 13RR
~~~I~J~R 114
1. A. FULL NAME
FIRST
a.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURI1Y NUMBER 063-66-6175
2. RESIDENCE A. N;~ATE) B. fJJd~ess
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
AND
SPECIFY Beacon
D. STREET ADDRESS 40 De19V~n Avp.n1Ip. ZIP 1 ?nOR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? cY YES 0 NO
3 A. AGE 29 3B. DATE OF BIRTH MoA4 / 024 / yJP81
4. EMPLOYMENT
A. USUAL OCCUPATION Technical Director
B. TYPE OF INDUSTRY OR BUSINESS Non-profit
5. PLACE OF BIRTH g~~~~~i&~i~M)T~~)
6. FATHER
A. NAME Paul Joseph ZrodlOl.vski
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Sandra loan Banko
8. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(2) 0 DEATH
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH OAY 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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
K~~c&nn DonoliMlliNT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. s~S~~~~~~~~~t~~~~~sJrodlowski
D. SOCIAL SECURI1Y NUMBER OR9-70-~4~ 1
12. RESIDENCE A. N';(TATE) B. qMt~J:J)ess
c. CHECK ONE 0 CITY [ill' TOWN 0 VILLAGE
AND 'A' .
SPECIFY vvapplnger
o STREET ADDRESS 1 ~~ Np.w H~r.kAn~~ck Rd ; ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
~~H /"n~ /WA~1
13. A. AGE 29
14. EMPLOYMENT
A. USUAL OCCUPATION Bar Manager
B. TYPE OF INDUSTRY OR BUSINESS Rp.!';t~llr~:mt
15. PLACE OF BIRTH MOllnt Kisco Nj'
(CITY, STATE / COUNTRy'lF N USA)
16. FATHER
A. NAME Unkno'A'n
B. COUNTRY OF BIRTH Ilnknnwn
138. DATE OF BIRTH
17. MOTHER
A. MAIDEN NAME Rit9 lane nnnohllp.
B. COUNTRY OF BIRTH II S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
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
,.
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
4TH
I duly swear/affirm, depose and say that
as to my right to enter into the marn e
21. SIGNATURE OF GROOM~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
best of my knowledge and belief that the information I provided is tru a
o
o
o
This license authorizes the marriage in New Yo 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
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en
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{ SEAL}
"-v-I
NAME (PRINT)
DATE 08/31/2010
by New York Domestic
TIME
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
MONTH
YEAR
10:54'M
PM
30 2010
2010
10
09
01
C TYIT N
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
TATE
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 00n:.t!e3"S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY ~ a\(!Dj..J
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
-ID
29. OFFICIANT
NAME (PRINT)
TITLE
DATE
NAME (PRINT)
SIGNATURE~