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COUNn' Dutchess
CITYfTOWN Wappinger
~~~:~c~ 1368 .
~~~~J~R 126
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Christopher Thomas Heady
MIDDLE CURRENT SURNAME
I
I
STATE ALE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
~
1. A. FULL NAME
FROM THE BRIDE
Karen Ann McMahon
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Monopoli
c. SURNAME AFTER MARRIAGE Heady
(OPTIONAL. SEE REVERSE) 087-68-9948
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE)...J (COUNTY)
C. CHECK ONE 0 CITY LJ TOWN 0 VilLAGE
~~~CIFY WapQinger
D. STAEETAODRESS 95 New Hackensack Rd. ZIP 12b9U
E. IS RESIDENCE WITHIN LIMITS OF cln OR INCORPORATED VILlAGE? 0 YES d NO
07 /08 /1967
DAY YEAR
FIRST
11. A. FULL NAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 069-70-2026
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r!!! TOWN 0 VilLAGE
~~~CIFY WappinQer
o STREET ADDRESS 95 New Hackensack Rd. ZIP
12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d' NO
12 / 26 / 1970
MONTH DAY YEAR
13. A. AGE 39
3. A. AGE 35
3B. DATE OF BIRTH
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Motor Equip. Operator
B. TYPE OF INDUSTRY OR BUSINESS Town of Wapp. Highway
5. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Glenn Thomas Heady
B. COUNTRY OF BIRTH USA
14. EMPLOYMENT
A. USUAL OCCUPATION Data Analyst
B. TYPE OF INDUSTRY OR BUSINESS Carecore National
15. PLACE OF BIRTH Yonkers, New York
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Vincent Monopoli
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Lorraine Ciccarelli
'B. COUNTRY OF BIRTH USA
2
18. NUMBER OF THIS MARRIAGE
7. MOTHER
A. MAIDEN NAME Ursula Diana Asendorf
B. COUNTRY OF BIRTH Germany
B. NUMBER OF THIS MARRIAGE 2
w
en
z
w
o
::i
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVO~CE CIVil ANN~lMENT DEAbH DIV~RCE CIVil AN'iYLMENT
~ ~
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (882EATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVOR154 (3) Dd~ULMENT 2db9 DEATH
C. DATE LAST MARRIAGE ENDED? 04/ 17 / 2 ' C. DATE LAST MARRIAGE ENDED? / /
MONTH ~ DAY YEAR MONTH ~ DAY' - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
~
10. IF PREVIOUSLY DIVORCED OR ANNUllED, PROVIDE THE FOllOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DA)';-,YEARl.. (CITYICOUNTY, STATElCOUNIfjY, IF NQT,USAk SELF SPOUSE (~~ Pl\Y2~Fj) C(CITY/COUl'fTY.IlTAT~OpNTflY, IF NOT USA) SELF SPOUJE
1ST 04/17/~00~ Poughkeepsie, New yor D~ 0 1ST U4/U:J/ UUl armel, I''lew YOrK 0 0
2ND 0 D 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affinn, depose and say, that to the best 0 my knowledge and belief that the infonnation I provided is true and that I declare that no legal impediment exists
as to my right to enter into the rn ge st te. ~ I; .1 I/o /J. ~
21. SIGNATURE OF GROOM~ . rr- 22. SIGNATURE OF BRIDE~ L/UL. )\..{.G~ L--
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME E CUR . USE CURRENT NAME 08/16/2006
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to per/onn 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 CITYJC RK C M t 25 A SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) 0 n . as erson . .
TIME
DE'1)H
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
'-v-I
MONTH
DAY
YEAR
YEAR
MONTH
DATE 08/16/200
appinger Falls, NY 12590
SIGNATURE ~
MAI~ '100
ZIP
,f-.M
05:34:>M
10
15 2006
2006
08
17
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
CITYITOWN STATE
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
DAY YEAR 0" RELIGIOUS
-z,ooG. 90 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNn'
J:, vfckt s
1 D CIVil
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF lil' TOWN OF 0 VilLAGE OF
~CA~ ~
29. OFFICIANT
NAME (PRINT)
TITLE
ZJr{)4-
SPECIFY
U1Jf 6.54;:;'11