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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:kc~ 1368
~~~~~~R 60
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Sr.ntt r.hri~tnrhp.r S~ttp.rlp.p.
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.-J
1. . A. FULL NAME
11. A. FULL NAME FIRST Eliza~D~~p Mary D2~~~NT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT~~II~ghp.r
C. SURNAME AFTER MARRIAGE S~ttp.rlp.e
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 112-58-5924
12 RESIDENCE ANY sDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D STREET ADDREsJl Cloverdale Place
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 081-72-1246
2. RESIDENCE A. NY B. nlltr.hp.~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY..tJ TOWN 0 VILLAGE
AND W '
SPECIFY applnger
D STREET ADDRESS 9 Cloverdale Place ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..o NO
12 /1!1 /1!=l74
MONTH DAY YEAR
ZIP 12590
DYES "6 NO
;(972
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE~R 3B. DATE OF BIRTH 04 /.58
MONTH DAY
3. A. AGE 33
38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION T p.~r.hp.r
B. TYPE OF INDUSTRY OR BUSINESS WCSD
5. PLACE OF BIRTH 9c~~~~~ 'cO~,xRY IF NOT USA)
6. FATHER
A. NAME r.hri~tnrhp.r I ynn S~ttp.rlp.p.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Christy Kay Steves
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
14. EMPLOYMENT
A. USUAL OCCUPATION Elementary Teacher
B. TYPE OF INDUSTRY OR BUSINESS Haldane CSD
15. PLACE OF BIRTHMineola. Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME James Joseph Gallagher
. 8. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAME Maureen Ellen Fitzgerald
B. COUNTRY OF BIRT~ S A
lB. NUMBER OF THIS MARRIAGE 2
a:'
w
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:;:
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH 8. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
/ / C. DATE LAST MARRIAGE ENDED? 07 / 26 / 2004
MONTH DAY YEAR MONTH DAY ~ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? i!'fYES 0 NO
~
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 07/26/2004 Dutchess County. Ny 0 l!'l
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/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 right to enter Into the mar estate, I...I!:.~
21. SIGNATURE OF GROOM . ' 22 SIGNATURE OF BRIDE ~ U L~ f2R_
USE C USE CURRENT NAME .
23 ~::~:T~~~Do~N.fo~~Ocf~ 6~A~~=E~ BEFORE ME DATE 06/04/2 8
This license authorizes the marriage in New rk State of the bride and groom named above by any person authorized by New York Domestic
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
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
DEATH
o
C. DATE LAST MARRIAGE ENDED?
~
{ SEAL }
'-..,-I
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON,
NAME (PRINT)
MONTH
TIME
MONTH
YEAR
DAY
YEAR
06/04/2008
NY 12590
STATE ZIP
27. TYPE OF CEREMONY
o ct RELIGIOUS
9 0 OTHER, SPECIFY
AM
04:35 PM 06
2008
08
03 2008
05
ITY
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY )(,(tc,hl! 55
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF g TOWN OF 0 VILLAGE OF
10 CIVIL
1
ICf
08
II
~~~t~~~~~ RObu7 8. Refl'" fli,
SIGNATURE~ ~ /2. ~ 13, tf1:L '';'''i.
MAILING ADDRESS ~
'O~ J4f,.KS,*, 5..}yuf (3oX/. F;s~ ,'/I
STREET J CITYfTOWN
30. WITNESS TO ~MONY . \./ ~
NAME(PRINT) l~ T~ \ , ~ '\.
"~"">^ .. A'
TITLE Ca.fl.oli, Pries.f.
DATE 7!tfi!D!
NY
STATE'
SPECIFY h -sh K// I
31.
NAME (PRINT)
SIGNATURE~
SIGNATURE~