006
Il.
N
+
!z
W
V>
W
III
o
...J
::l
O'
J:
V>
Z
o
~
(!j
W
a:
W
~
it:
a:
:i
u.
o
W
8
iL
~
W
U
W
a:
W
~
V>
V>
W
a:
o
o
<
~
o
W
<L-
V>
rr.'
w
III
:I
::>
'"
Q
~
Iii
w
~
+
~~~ W
i= l: ~ ....
ll!~~ c:(
li;~~ 0
::lUW
~~g u::
~i~ ~
!tav> W
Of-> 0
w~~
t-ffilO
~g~
COUNTY Dutchess
CITYfrOWN Wappinger
~~~:~ 1368 '
~3~~~~R 6
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ralph Michael Sheehan
MIDDLE CURRENT SURNAME
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~g~~e Jenkin~URRENT SURNAME
~
1 , A. FULL NAME
11. A, FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 098 64 2338'
D. SOCIAL SECURI1Y NUMBER --
2. RESIDENCE A. NY B, Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Waooinaer
D. STREET ADDRESS P.O. Box 401 ZIP 12537
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
3. A. AGE 43 3B. DATE OF BiRTH 02 / 25 / 1964
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Sheehan
(OPTIONAL - SEE REVERSE) 116 72-3020
D. SOCIAL SECURI1Y NUMBER -
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY l!f TOWN 0 VILLAGE
~~~CIFY WappinQer
D. STREET ADDRESS P.O. Box 401 ZIP 12537
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES r1 NO
Al9 /1974
DAY YEAR
13. A. AGE 33
3B. DATE OF BIRTH
12
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Auto Body Technician
B. TYPE OF INDUSTRY OR BUSINESS Automotive
5. PLACE OF BIRTH Poughkeeosie. NY
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Ralph Edward Sheehan
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Jean Marie Herring
B. COUNTRY OF BIRTH U S A
8. NUMBER OF THIS MARRIAGE 1
9. ~~~~~~lRMtFR~~"'E<t~8us MARRIAGES WHICH ENDED BY
..DIIIORGE-__________ .CJIII.kANNULMENI.
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Grocer
B. TYPE OF INDUSTRY OR BUSINESS Retail
15. PLACE OF BIRTH North Tarrvtown. NY
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME James Joseph Jenkins
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Maraarete Reuter
B. COUNTRY OF BIRTH Germanv
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
(2) 0 DEAJI'i
. (3) [3,ANNULMENT (2) 0 DEATH
/ /
,'- YEAR
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
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) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
YEAR
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) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and
as to my right to enter into the
21. SIGNATURE OF GROOM
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
t of my knowledge and belief that the information I provided is true and t at
o
o
o
22. SIGNATURE OF BRIDE ~
23. SUBSCRIBED AND SWORN TOIAFFI MED BEF
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York 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
DATE 01/17/2008
by New York Domestic
W
en
z r-^-..
W
~ {SEAL}
'-v-'
NAME (PRINl)
YEAR
MONTH
YEAR
TIME
MONTH
AM
02:34PM
03
17 2008
01
18
2008
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
ITY WN
26. SOLEMNIZATION OCCURRED
TIME M . AY YEAR
CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. CO~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF ~LLA~F II.
SPECIFY tiJlf.l:Ptlv6f..;t.l? ~
29. OFFICIANT
NAME (PRINl)
o
.
NAME (PRINl)
SIGNATURE~
DoH-9S (0312006)
SIGNATURE~
