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Dutchess
COUNTY . . . .
VVC:lpplflger
CITYfTOWW B
DISTRICT I 35 .
~~~I~~~R 64
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Christopher O'Sullivan
r
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROMTH~ BRIDE
Kern Ann Brady
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), 1~IF~Rijt!T
U "ulllvan
C. S~S~~N~'::~~~t~WC~~SE)O 15-62-90 15
D. SOCIAL SEIO.~JY NUMBER F"\ t t
I'll T LJU c.; le::;~
12. RESIDENCE A. B.
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) UbL-b4-U4b 1
D. SOCIAL SEC\lfIJ~NUMBER D t ~
I'IIT U Clless
2. RESIDENCE A. B.
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION
Teacher
A. USUAL OCCUPATION Educ.atioll Calli lei Gelltl'al
B. TYPE OF INDUe-Fo'8IH~ClftN<Ma
l
15. PLACE OF BIRTH
6. FATHER
A. NAME
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER Gerald Leo Brady
A. NAME . USA '.
B. COUNTRY OF BIRTH
James P. O'Sullivan
U$A
B. COUNTRY OF BIRTH
7. MOTHER
17. MOTHER
Marcia Ann Khoury
USA
B. COUNTRY OF BIRTH 1
A. MAIDEN NAME
Ann C. Cullen
USA
1
18. NUMBER OF THIS MARRIAGE
19, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH EN OED BY
DI'(5lRCE CIVIL AN(;ULMENT
DEOT.H
A. MAIDEN NAME
B. COUNTRY OF BIRTH
8. NUMBER OF THIS MARRIAGE
9, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1V~CE CIVIL AN~LMENT
DEtJH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. '.~ YEAR'
YEAR
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
,.
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and sa
as to my right to enter into the
21. SIGNATURE OF GROOM~
o
o
o
1ST
2ND
3RD
o
o
o
o
exists
MONTH
YEAR
10
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
CITYITOWN
26. SOLEMNIZATION OCCURRED
TIME M. DAY YEAR
I () AM 011 I ~- i..oaq
PM
~~~l~~~~~T _4:'(; v. 0 NAN A .1> I-} A C;
SIGNATURE ~ ~ y"",
MAILING ADDRESS .. ~~
II ~L'N,D>{ gr fAJA-PPIAJ.4~.R.'\ ~AuS
STREET CITYrrOWN
30. WITNESS Ti).EMONY
, .
NAME (PRI ~ 1"1..,. J
SIGNATURE~ 1
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY j u7'eI4Bs~
TITLE 'PARoc/-/.tAL. vle.A-~
DATE ~ I ,~ / ~cPI
, I
NY 12.$-Qo
STATE ZIP
31. WITNESS TO CEREMONY /' .
NAME (PRINT) ~O r I
SIGNATURE~ r A;) 1 '
SPECIFY /)J.A P P ; Nit L~ ~<>.
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