028
,~
~
w
>-
<(
>-
,,'"
N
o
o
00
\Z ot: >
~u
~Q) c(
o~ Q
5~ ~ u::
~~ 5 LL.
",>:i _
Z ell ~-
Q.~ :;:
~~o
CI: 0 l::
!ii ,-:d~
"
'"
CI:
w
"
<(
ii: <1l
~~
H
<1l
~;>
u.. 0
;:: 0
~::t:
~rC
CI:.l-l
~~a:
~ 0 l:l
~CI)~
'" z
~LI') ~
00'1 <(
;N E
u. a:
@ 1;;
0-
m
~~~ W
tu~~ t:
CI:CI:- _
~~~ (J
::lOLU
~!Eg u::
1~ ~
or" W
~~ (J
sm~
z3~
0-
N
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Allyn F.
FIRST MIDDLE
COUNTY
CITYfTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
Dutchess
Wappin~er
1368
28
Stavanau II
1. A. FULL NAME
CURRENT SURNAME
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERS~28_49-2684
D. SOCIAL SECURITY NUMBER
2 RESIDENCEA. Colorado B. Boulder
(STATE) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~CIFY Louisville
o STREET ADDRESS 295 South Hoover Ave. ZIP 80027
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? ~ YES if NO
3. A. AGE 28 3B. DATE OF BIRTHMa y / 0 / 971
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION
Computer Support Tech.
IBM
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACEOFBIRTH St. Paul l1inncsota
(CITY. STATE/COUNTRY I' NOT USA)
6. FATHER
A. NAME
Allyn
F.
USA
Stavanau
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME Velma Lou Westmoreland
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE Firs t
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
(2) C DE.ATH
B. HOW DID LAST MARRIAGE END? 13).::J DIVORCE 13) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) ICITY, STATECOUNTRY. IF NOT USA) SELF SPOUSE
(THIS SPACE FOR STATE USE ON/. Y)
/r,\"i"
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Erika s.
~
Po1i
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE S tav anau
(OPTIONAL - SEE REVERSE) 099-70-6258
D. SDCIAL SECURITY NUMBER
Colorado Boulder
12. RESIDENCE A. (STATE) B. (COUNTY)
C. CHECK ONE M CITY If' TOWN VILLAGE
AND L 9 '1
SPECIFY ou~sv~ e
295 South Hoover Ave
D. STREET ADDRESS
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE?
13. A. AGE 26 13.B. DATE OF BIRTH March /
MONTH
tsOO.u
ZIP
~
13
DAY
YES 0 NO
YJ74
YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Supervisor
B. TYPE OF INDUSTRY OR BUSINESS Rock Bottom Restaurant
15. PLACE OF BIRTH poughkeepsie,New York
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME
Steven Po1i
USA
B. COUNTRY OF BIRTH
17. MOTHER
Bonnie M. Feiler
B. COUNTRY OF BIRTH USA
A. MAIDEN NAME
18. NUMBER OF THIS MARRIAGE
First
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
3\ = ANNULMENT
/ /
(2) C DE.ATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? = YES = NO
20. iF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
,MONTH. DAY. YEAR) (CITY. STATElCOUNTRY. IF NOT USA\ SELF SPOUSE
D
1ST
2ND
3RD
4TH
I. being duly sworn. depose and sa
as to my right to enter into the m
21. SIGNATURE OF GROOM ~
1ST
2ND
3RD
o 4TH
t of my knowledge and belief that the information I provided is true and that I decla
23. SUBSCRIBED AND SWORN TO BEFO 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 pertorm marriage ceremonies within New Yor\( 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
Town Clerk
:]
'--'
w
en
z
w
(J
::i
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
~AII.ING ~DRE
'-v-' t' . U. .!Sox
S
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIM A Y
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE 4/3/00
NY 12590
04
04
:-;
:J
'--'
DATE
L\--~-c.o
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIONIGHT ON:
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
AM
1: 10 PM
00
06
02
00
'1:
27. TYPE OF CEREMONY
o It RELIGIOUS
9 0 OTHER. SPECIFY
1 r CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ['u\c.f-o)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFY WOprt(\:f"'S tC1l~
nJ a... -t z.... DATE ~ .;l') .2'Ca1
, Wo Pf)it1~O 1m Q 'I.S} N r IdSqO
STATE ZIP
, 31. WITNESS TO CEREMONY
co
29. OFFICIANT Q <II:.~....l n M
NAME (PRINT) 'lev. ..JQ I ~ (("L. I'"') Qr')'1' z..
SIGNATURE ~ ~..., ~2',(Oo.a . t1J.
MAILING ADDReF'
~ t-Jt:iler Qu!'.(\. ve.. J ~I
STREET ClTYfTOWN
30. WITNESS TO ~RE~Y
NAME (PRINT)
TITlE
1'"'1 ini~+ e r
NAME (PRINT)
SIGNATURE ~