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COUNTY Dutchess
CITYrrOWN Wappinger
DISTRICT 1368 '
NUMBER
~~~I:~R 64
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Adam Thomas Lauricella
MIDDLE CURRENT SURNAME
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Keely Lou Sheehan
MIDDLE CURRENT SURNAME
-.J
, . A. FULL NAME
, ,. A. FULL NAME
FIRST
FIRST
a.
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 064-66-4585
D. SOCIAL SECURIlY NUMBER
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r:::J'ITOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 5 Dorothy Heights
E. IS RESIDENCE WITHIN UMITS OF CITY DR INCORPORATED VILLAGE?
3. A. AGE 30 3B. DATE OF BIRTH 10 / 12 /
MONTH DAY
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 256-21-8619
D. SOCIAL SECURIlY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY D""'TOWN 0 VilLAGE
~~~CIFY Wap~inger
D. STREET ADDRESS Dorothy Heights
12590
ZIP
12590
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES D""'NO
04 / 04 /1975
MONTH DAY YEAR
DYES D""'NO
197
YEAR
32
3B. DATE OF BIRTH
13. A. AGE
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION
Unemployed
A. USUAL OCCUPATION Tattooer
B. TYPE OF INDUSTRY OR BUSINESS Graceland Tattoo
5. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE / COUNTRY IF NOT USA)
B. TYPE OF INDUSTRY OB BUSINESS
15. PLACE OF BIRTH Buttalo, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Terrance H. Sheehan
'B. COUNTRY OF BIRTH USA
17. MOTHER
6. FATHER
A. NAME Alfred Albert Lauricella
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Patricia Margaret Tomlin
B. COUNTRY OF BIRTH USA
1
8. NUMBER OF THIS MARF:lIAGE
9. PREVIOUS MARRIAGES '
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORBE CIVIL ANNUlfENT
A. MAIDEN NAME Patricia L. Spangenberg
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
~A.NUMBEft..OF~I?RE-VIOUS,MAREIIAGESWHICH_ElIIDED.BY
DIVOdCE CIVIL ANN~ENT
DEA~
DEAT5
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,',- YEAR
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, STATEICOUNTRY.IF NOT USA) SELF SPOUSE
B. HOW 010 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) (CITY/COUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.ose and I't t to
as to my right to enter into the m ma e
21. SIGNATURE OF GROOM.
o 0 1ST
o 0 2ND
o 0 3RD
o 4TH
belief that the Information I provided is t
o 0
o 0
o 0
o 0
pediment exists
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage In NewYDrk State authorized by New York Domestic
Relations Law !l11 to perform marriage ceremonies within New Y k 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 subse uent ceremony.
~ 24. TOWN OR CITY 5'0 K 25.A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)
SEAL SIGNATURE ~ DATE 06/28/200 YEAR MONTH
MAILI~lfOOffdle appinger Falls, NY 12590 200
'-v-' STREET CITYITOWN ZIP PM
~~~R~~R~~~ IO~O~~N~EE~ 26. SOLEMNIZATION OCCURRED
SONS NAMED ABOVE ON THE TI E MO. Y YEAR
DATE AND AT THE TIME AND jd /
PLACE INDICATED. 0'7 T J D7
YEAR
08
27 2007
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS 1 0 CIVIL
9Rr OTHER, SPECIFY &tJ'rrn,.n"\c.otJ
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 01~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY Nec..v -Pct.. \~
:~~);~ VY\,,\o~
Y I Q.;5'J ~
STATE ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~
,.j::lll'