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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~c~ 1368 .
~~~':~~R 63
~ I Alt: UF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mark Kevin Dugan JR
MIDDLE CURRENT SURNAME
., I "" II:. riLe. nUmD~"
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Lauren Christine Keenan
MIDDLE CURRENT SURNAME
-.J
1. A FULL NAME
11. A FULL NAME
FIRST
FIRST
a.
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Dugan
(OPTIONAL. SEE REVERSE)118 74 6409
D. SOCIAL SECURITY NUMBER --
12 RESIDENCE ANY B.Westchester
(STAlE) (COUNTY)
C. CHECK ONE "D CITY 0 TOWN 0 VILLAGE
~~~CIFY Peekskill
D. STREET ADDRES~-J Rolling Way ZIP 10566
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? "6 YES 0 NO
13. A. AGE26 3B. DATE OF BIRTH 03 ~4 ,%983
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 113-72-0352
2 RESIDENCE A. NY B. Westchester
(STATE) (COUNTY)
C. CHECK ONE olJ CITY 0 TOWN 0 VILLAGE
~~~CIFY Peeks kill
D STREET ADDRESS 5-J RollinQ Way ZIP 10566
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
12 /28 /1980
MONTH DAY YEAR
3. A. AGE ?R
3B. DATE OF BIRTH
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II)
4. EMPLOYMENT
A. USUAL OCCUPATION Auto Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Automotive
5. PLACE OF BIRTH Cold Spring. NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Mark Kevin Dugan, Sr
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Gloria Jean Benedict
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS NYCDOE
15, PLACE OF BIRTHPort Chester, NY
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Kenneth Lawrence Keenan
'B. COUNTRY OF BIRTJ.l S A
17. MOTHER
A. MAIDEN NAME Paula Marie Vaccari
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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DEATH
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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
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
MONTH DAY 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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swe!lr/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my nght to ent .!--.- te, ----J~ )
21. SIGNATURE OF GROOM ' / SIGNATURE OF BRIDE~~
USE CURRENT NAME
DATE 07/06/2009
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New ork 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
{ } NAME (PRINT) John C. Masterson
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE 07/06/2009
"- .-J MAIWtiG f.rJIPdB~
-v- LU IVI 01 ush Rd, Wappingers Falls, NY 12590
STREET CITYITOWN STATE ZIP
~~~R~~Ri~~~ lo~O~~~N~Zi~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME 0 DAY YEAR O~RELlGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
DAY
YEAR
MONTH
01 :25~~ 07
09
04 2009
07
2009
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B.~~J"7' de;,7eie
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~VILLAGE OF J~
te1e g/UJ cJtC
STREET
30. WITNESS TO CEREMONY
o tj/2-c(OM
NAME (PRINT)
SIGNATURE~
/?A./ S/2
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)