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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MI~~~n KAlly
COUNTYDutchess
CITYfTOwNWappinger
~~~~~~1368 .
~~~I~~~'1 09
1 . A. FULL NAME
FIRST
CURRENT SURNAME
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AffiR MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER ~ 27-72-0642
2. RESIDENCE ANY B. nlltr.hA~~
(STATE) (COUNTY)
C. CHECK ONE D CITMJ TOWN D VILLAGE
~~~CIFY Pleasant Valley
o STREET ADDRESS 1377 Route 44 ZIP 12569
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? D YESO'tJ NO
3. A. AGF~~ 3B. DATE OF BIRTH 1 ? /? 1 /1 ~ 73
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Excavation
B. TYPE OF INDUSTRY OR BUSINESS Ken Travis Excavation
5. PLACE OF BIRT~ooperstown. New York
(CITY, STATE / COUNTRY IF NOT USA)
....
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6. FATHER
A. NAME Kevin Kelly
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Corinne Alta Fay
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
. DIVORCE._. _.______._.._-CLVlLANI'lIl11.MENT__
o 0
.DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
to.IF-PREVIOtlSI:YDIVORCEDOR 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)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
MalJreen Teresa Brosnan
MIDDLE CURRENT SURNAME
~
1 1. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AffiR MARRIAGE K All Y
(OPTIONAL - SEE REVERSEb
D. SOCIAL SECURITY NUMBER 55-66-0275
12. RESIDENCE ANY BDutchess
(STATE) (COUNTY)
c. CHECK ONE D CITY..o TOWN D VILLAGE
~~~cl~leasant Valley
D. STREET ADDREss1377 Route 44
z,P12569
D YEMJ NO
:1-974
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGF.13 3B. DATE OF BIRTH 04 2b
MONTH DAY
14. EMPLOYMENT
A.. USUAL OCCUPATIO~eceptionist
B. TYPE OF INDUSTRY OR BUSINESSWest. OncoloQV
15. PLACE OF BIRT~ronx. New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMeCornelius Brosnan
'B. COUNTRY OF BIRT~reland
17. MOTHER
A. MAIDEN NAMEAnne McGrath
B. COUNTRY OF BIRTtU 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
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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that t
as to my right to enter into the marnage
21. SIGNATURE OF GROOM~
D 0 1ST
D 0 2ND
D 0 3RD
D 0 4TH
Y knowledge and belief that the information I provided is true a d that I declare that n
D
D
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US
23. SUBSCRIBED AND SWORN TO/AF IRMED BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the
Relations Law ~1 1 to perform marriage ceremonies within New York St
D If checked, this license is to be used on
~ 24 TOWN OR CITY CLERI$...
} NAME (PRINT) Jo c. Masterson
{SEAL SIGNATURE ~
'-v-I M~<Mr8m~b
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
bride and groom named above by any person authorized by New York Domestic
. THIS LICENSE VALID IN NEW YORK STATE ONLY.
for the purpose of a second or subsequent ceremony.
25. A. SOLlEMNIZATION PERIOD BEGINS
TIME
YEAR
YEAR MONTH
MONTH
AM 09
02:37 PM
01 2007 10 30 2007
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 7)o1C~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF ~WN OF D VILLAGE OF
SPECIFY W.,tJp?1/Il6/$/Z:""P :
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