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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Gre~I~'J Michael C~~~~ERNAME
I
STATE Fn:E NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
r
I
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c: 1368
~G~:~~R 137
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Cathleen Patricia Durcan
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 020-70-4376
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. MA B. Suffolk
(STA~ (COUNTY)
C. CHECK ONE I!f CITY 0 TOWN 0 VILLAGE
~~~CIFY Boston
D. STREET ADDRESS 366 Dorchester St., Apt. 7 ZIP 02127
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? dYES 0 NO
3. A. AGE 32 3B. DATE OF BiRTH 06 / 17 / 197
MONTH DAY YEAR
MONTH
13. A. AGE 30
3B. DATE OF BIRTH
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Nurse
B. TYPE OF INOUSIfIY OR BUSI~SS LJana t-arber HOSp.
15. PLACE OF BIRTH l:Seacon, New YorK
(CITY. STATE I COUNTRY IF NOT USA)
A. USUAL OCCUPATION Underwriter
B. TYPE OF INDUSTRY OR BUSINESS X S Brokers
5. PLACE OF BIRTH Boston, Massachusetts
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
6. FATHER
A. NAME John A. Power
B. COUNTRY OF BIRTH Ireland
A. NAME John Durcan
. B. COUNTRY OF BIRTH Ireland
17. MOTHER
A. MAIDEN NAME Breda Mc Donald
B. COUNTRY OF BIRTH Irelan,d
18. NUMBER OF THIS MARRIAGE
7. MOTHER
Anne P. Considine
A. MAIDEN NAME
Ireland
B. COUNTRY OF BIRTH
,
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1VO~CE CIVIL ANN~ENT
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL AN~LMENT
DEtJ'H
DEAlr
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 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) (C1!yICOUNTY, STATElCOUNTRY. IF NOT USA) SELF SPOUSE
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o 0 1~ 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
dge and belief that the information I provided is true and that I declare that no legal Impediment exists
(WIt 111-'< fJ/1 A < ~
USE ~RENT NAME 08/30/2006
DATE
by New York Domestic
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YEAR MONTH
YEAR
2006 1 0
DATE I
1>tlu1011 MI1E6 ~
STATE ZIP
28. PLACE WHERE MARRIAG~<:'U~ ,
A. STATE NEWYORK ~~C('j
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~N OF 0 VILLAGE OF
SPECI~'~J 4,e I} '7
SIGNATURE~
DOH-98 (0312006)
f'~
SIGNATURE~