The Republic of Poland Lubuskie Province Register Office in

The Republic of Poland Lubuskie Province Register Office in

[Remark of the translator: in the middle the National Emblem of the Republic of Poland ]
The Republic of Poland
Lubuskie Province
Register Office in Zielona Góra
Short Copy of the record of marriage
I. Particulars of the persons contracting marriage:
Man
Woman
1. Family name
[not filled]
[not filled]
2. Name(s)
Leszek Adam
Monika Maria
3. Surname at birth
[not filled]
[not filled]
4. Date of birth
on 17 August [not filled]
on 20 January [not filled]
5. Place of birth
Lubsko
Nowa Dęba
II. Date and place of marriage
1. Date: on the ninth of November [not filled] (09.11. [not filled])
2. Place: Drzonków
III. parents particulars:
A. Father
1. Name(s)
Wiesław Józef
Tadeusz Stanisław
2. Surname at birth
[not filled]
[not filled]
B. Mother
1. Name(s)
Urszula
Jadwiga Elżbieta
2. Surname at birth
[not filled]
[not filled]
IV. Surname assumed upon marriage:
1. Man: [not filled]
2. Woman: [not filled]
3. Children: [not filled]
V. Annotations about divorce, annulment or separation:
[not filled]
Place Stamp Duty
Exempt from stamp charge - Legal basis: part II, column 4 item 2 letter B of the Appendix to the Stamp
Charge Act consolidated text of 21.11 [not filled] (The Journal of Laws Dz. U. item 1282 from [not filled]).
Seal
[In the middle the round, red seal with the National Emblem of Poland in the rim and the following inscription: „Register Office in
Zielona Góra”]
Certified to be a true copy of entry of marriage no. 707/ [not filled].
Zielona Góra, on 12.11. [not filled]
Tłumaczenia Mickiewicz · ul. Kąpielowa 10B, 65-383 Zielona Góra · Tax Identification No.: 928-184-43-60 · Company no. REGON: 080440573
Tel.: (0048) 669-259-424 · Email: [email protected] · Website: www.tlumaczeniamickiewicz.pl
Registrar
[On the right side the longitudinal, red name stamp with the following inscription: „Elżbieta Kaczmarek · Deputy Registrar”]
[Signature illegible]
M-13 „Technika IT”, Gliwice
118/13/07
Tłumaczenia Mickiewicz · ul. Kąpielowa 10B, 65-383 Zielona Góra · Tax Identification No.: 928-184-43-60 · Company no. REGON: 080440573
Tel.: (0048) 669-259-424 · Email: [email protected] · Website: www.tlumaczeniamickiewicz.pl