079
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brian Thomas Callanan
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITY/TOWN Wappinger
~~J:~: 1368 .
~5~I~l~R 79
1 . A. FUll. NAME
FIRST
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B. BIRTH NAME, IF DIFFERENT
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C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 134 68 3889
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. New York B. Putnam
(STATE) (COUNTY)
C. CHECK ONE 0 CITY f!'I' TOWN 0 VILLAGE
~~CIFY Garrison
D. STREET ADDRESS 1760 Route 9, Apt. 1 A
ZIP 1 0524
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORAlED VILLAGE? 0 YES ~ NO
02 / 27 / 1985
MONTH DAY YEAR
3. A. AGE 21
3B. DATE OF BiRTH
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6. FATHER
A. NAME Richard Callanan
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Linda Stahl
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV08CE CIVIL ANN~LMENT
DE,6er
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEAJH
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, STATEICOUNffiY.IF NOT USA) SELF SPOUSE
5TAT~ FIL~ NUMB~R
(THIS SPACE FOR STA TE USE ONL Y)
Lo
SUPPLEMENTAL FILE
FROM THE BRIDE
Jessica Liane Scull~
MIDDLE CURR NT SURNAME
11. A. FUll. NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Callanan
(OPTIONAL - SEE REVERSE) 078-68-5850
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Putnam
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r::! TOWN 0 VILLAGE
~~CIFY Garrison
D. STREET ADDRESS 1760 Route 9 Apt. 1 A ZIP 10524
E. IS RESIDENCE WI11iIN UMITS OF CITY OR INCORPORAlED VILLAGE? 0 YES 6 NO
13 A. AGE 23 3B. DATE OF BIRTH 04 /27 /1983
. MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Cashier
ii. TYPE OF INDUSTRY OR Bl!~~ESS A & P
.11i...PLAC.E..OF.BIRTH Mount KISCO, New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Dennis Charles Scully
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Karen Jane Martin
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
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
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) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
Y knowledge and belief that the Information I provided is t
o
o
o
SE CUR ENT
23. SUBSCRIBED AND SWORN TO/AFARMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the malTiage in New York State of authorized by New York Domestic
Relations Law ~11 to pertonn malTiage ceremonies within New York tate. THIS LICENSE VALID IN NEWYORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITJ81lW C. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME(PRINT) ~ ~
SEAL SIGNATURE ~ e. ~ DATE 06/26/200
'-v-' ....,~- h Rd, W --~~~er ;;;'115, NY 12590
STREET CITYITOWN . STATE ZIP
~~RJ~R'f,tl~llo~~~N~:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME AY Y ROO RELIGIOUS
~tI~E ~gIC'i.~~E TIME AND , A 9 0 OTHER, SPECIFY
21. SIGNATURE OF GROOM
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YEAR
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28. PLACE WHERE MARRIAGE OCCURRED
STATE NEW YORK B. COU~\ ~~
LOCATION OF CER ONY
(CHECK ONE AN PECIFY)
o CITY OF TOWN OF 0 VILLAGE;.OF
SPECI~l~~~