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COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~ 1368 '
~~~~R 112
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael Joseph Cahill
MIDDLE CURRENT SURNAME
STATE FILE NUM8ER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Debbie Ann Botscheller
MIDDLE CURRENT SURNAME
.-J
L A FULL NAME
11, A, FULL NAME
FIRST
FIRST
0..
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Cahill
(OPTIONAL - SEE REVERSE) 112-60-9629
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE)..J (COUNTY)
C. CHECK ONE 0 CITY Ll TOWN 0 VILLAGE
AND W .
SPECIFY apQlnger
D. STREET ADDRESS 19A Alpine Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 6 NO
06 /28 /1973
DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 089-72-5453
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~CIFY Wappinger
D. STREET ADDRESS 19A Alpine Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d' NO
3. A. AGE 34 3B. DATE OF BIRTH 12 / 04 / 1971
MONTH DAY YEAR
13. A. AGE 33
3B. DATE OF BIRTH
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Nurse
B. TYPE OF INDUSTRY O!,\ B.lWINESS Bethel NurSing
15. PLACE OF BIRTH Nortn I arrytown, New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Ernest John Botscheller
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Ellen J. Mcinerney
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL AN~LMENT
D~H
4. EMPLOYMENT
A. USUAL OCCUPATION Driver
B. TYPE OF INDUSTRY OR BUSINESS Richard's Lumber
5. PLACE OF BIRTH Queens, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Michael JOSeRh Cahill
B. COUNTRY OF BIRTH U S
7. MOTHER
A. MAIDEN NAME Phyllis Barnot
USA
B. COUNTRY OF BIRTH
1
8. NUMBER OF THIS MARf:lIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV08CE CIVIL ANN~LMENT
DEA~r
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affinn. depose and say, that to the
as to my right to enter into the mamage .
21. SIGNATURE OF GROOM ~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
Y knowledge and belief that the infonnation I provided is true an
o 0
o 0
o 0
o 0
that I declare that no legal impediment exists
~
URE OF BRIDE ~
USE CURRENT NAME
08/02/2006
23. SUBSCRIBED AND SWORN TO/AFFIRM 0
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes lhe marriage in New York State of authorized by New York Domestic
Relations Law ~11 to perfonn marriage ceremonies within New Yo tate. 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 C~8fl~ C. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
~
{ SEAL }
'-v-I
YEAR
YEAR
MONTH
DATE
pinger Falls, NY 12590
2006
10
01 2006
ZIP
STATE
27. TYPE OF CEREMONY
o ~L1GIOUS .10 CIVIL
9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B.~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF
NAME (PRINT)
SIGNATURE~
OOH-98 (0312006)