No preview available
033 a. N + ~ Z UJ (/) UJ <D o ...J ::J O' I (/) Z o f= '"' cr: ~ (/) a UJ cr: UJ (!) '"' ir cr: '"' :; "- O' UJ ~ '"' u u: f= cr: UJ u UJ cr: UJ' I ;: (/) (/) UJ cr: o o '"' ~ "- C3 UJ 0- (/) + STATE OF NEW YORK DEPARTMENT OF HEALTH AFADAVIT,UCENSEand CERTIFICATE OF MARRIAGE FROM THE GROOM Craig J. Skellv MIDDLE CURRENT SURNAME COUNTY Dutchess CITYrrOWN Wappinger ~~~:kCRT 1368 ~~~li~~R 33 1. A. FULL NAME FIRST B. BIRTH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL' SEE REVERSE) 084 58 1275 D SOCIAL SECURITY NUMBER -- 2 RESIDENCE A. NY B. Dutchess (STATE) (COUNTY) C. CHECK ONE D CITY ~ TOWN D VILLAGE ~~~CIFY Waooinaer D STREET ADDRESS 5 Wildwood Drive; Apt 3B ZIP 12590 E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES tJ NO 03 / 11 / 1976 MONTH DAY YEAR 3. A. AGE 32 3B. DATE OF BIRTH 4. EMPLOYMENT A USUAL OCCUPATION Accountant B. TYPE OF INDUSTRY OR BUSINESS AccountinQ 5. PLACE OF BIRTH Bronx. New York (CITY. STATE / COUNTRY IF NOT USA) 6. FATHER A. NAME Eugene F Skelly B. COUNTRY OF BIRTH USA 7. MOTHER A MAIDEN NAME Rose Marie Visconti 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 DEATH o B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT / / (2) D DEATH C. DATE LAST MARRIAGE ENDED? 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) (CITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE I STATE FILE NUMBER (THIS SPACE FOR STA TE USE ONL Y) I L 0 SUPPLEMENTAL FILE FROM THE BRIDE Samantha R. McKeon MIDDLE CURRENT SURNAME ~ 11 A. FULL NAME FIRST 13. A. AGE 24 05 MONTH 3B. DATE OF BIRTH 14. EMPLOYMENT A USUAL OCCUPATION Medical Technician B TYPE OF INDUSTRY OR BUSINESS Medical 15. PLACE OF BIRTH North Tarrytown, NY (CITY. STATE I COUNTRY IF NOT USA) 16. FATHER A NAME Thomas Warren Mckeon . B COUNTRY OF BIRTH USA 17. MOTHER A. MAIDEN NAME MarQaret Mary Alexander B. COUNTRY OF BIRTH USA 1B. NUMBER OF THIS MARRIAGE 1 19. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT o 0 DEATH o B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH C. DATE LAST MARRIAGE ENDED? / (. MONTH DAY YEAR D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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 D D 1ST D 0 2ND D D 3RD D 0 4TH Y knowledge and belief that the information 1 provided is true D D D D D D D D hat I declare that no legal impediment exists - USE CU 23. SUBSCRIBED AND SWORN TO/AFFIRMED EFORE ME SIGNATURE OF TOWN OR CITY CLERK ~ This license authorizes the marriage in New Y r) State of the bride and groom named above by any person authorized Relations Law ~11 to perform marriage ceremonies WI in New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY. D 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) 21. SIGNATURE OF GROOM~ w en z w o ::i ~ { SEAL } '-.t-I DATE 04/18/200 F lis NY 12590 STATE ZIP 27. TYPE OF CEREMONY . / 1 [j'" CIVIL AM 01 :08PM 04 19 2008 06 17 2008 Z' . ~E~ w ~;:~ ~ ll!~~ .., ~ UJ z .... 3d~ 0 ~~g u:: ~~~ ~ [O(/) W o~~ w~15 0 5~"' Z :J ;:; NAME (PRINT) SIGNATURE~ . 22, SIGNATURE OF BRIDE ~ DATE 04i18i2008 by New York Domestic TIME MONTH YEAR MONTH YEAR 2B. PLACE WHERE MARRIAGE OCCURRED A. STATE NEW YORK B COUN~lJ.~H<i. ~ C. LOCATION OF CEREMONY (CHECK ONE AN~PECIFY) D CITY OF ~TOWN OF D VILLAGE OF SPECIFY vJ~i ~e.~vt STATE 31, NAME (PRINT)