016
~
.....
>-
z
i
I
i
a:
I
.
I
i
I
~
'"
'"
w
a:
o
o
<(
>-
LL
<:3
w
"-
'"
o
2iz
~~g UJ
~~~ ~
t-ffiZ <(
gjdr5 ()
~~~ u:::
z-
~~t) t=
ito", a:
0>->- UJ
W:Jj;3 ()
b~U>
Z::::i~
COUNTY~
CITYlTOWN \Nappll"\g8r
~~r~~~C~1388
~5~,I~J~R1S
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~
I STATE FILE NUMBER
I (THIS SPACE FOR STATE USE ONL Y)
U~ :f;:!;
L [J SUPPLEMENTAL FILE
I
~1fW
I/~
A. FULL NAME
Mir.NMI .~ C"..ahiI1
FIRST MIDDLE
FROM THE BRIDE
11. A. FULL NAME ~ Ann BalBcheHer
FIRST MIDDLE
CURRENT SURNAME
CURRENT SURNAME
"-
N
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE"","^
D SDCIAL SECURITY NUMBER l~n-545.~
2 RESIDENCE A ......, V 011( B nlJfl'hAc.ct
~AttJ ~
C CHECK ONE 0 CITY.tJ TOWN 0 VILLAGE
AND \~
SPECIFY . .~nger
D STREET ADDRESS 1M Alpine DrIve ZIP 12590
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES.tJ NO
3. A. AGE34 3B. DATE OF BIRTH M1~H /O:tY /1~1
4. EMPLOYMENT
A. USUAL OCCUPATION l1river
B. TYPE OF INDUSTRY OR BUSINESS ~ lumber
5. PLACE OF BIRTH~~C~IIX~A'
6. FATHER
A. NAME Michael Cahill
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Phyllis Bernet
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Cahill
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 112-60-9629
12. RESIDENCE ANew Xnrk B. rlIf^'lMa
C. CHECK ONE (STAd' CITY ~ TOWN 0 VILLAGE ( OUNTY)
AND 'a.......
SPECIFYV1All....ouer
O. STREET ADDREss1M Alpine DrIve ZIP12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'I!"J NO
13. A. AGE32 13.B. DATE OF BIRTH M r.ft 4~
~NTH e.o DAY ,W ~AR
w
>-
<<
>-
<fJ
14. EMPLOYMENT
A. USUAL OCCUPATIONNurse
B. TYPE OF INDUSTRY OR BUSINESSBethaI Nursing
15. PLACE OF BIRTH~T!~T~Yortc
16. FATHER
A. NAMEEmest John BabIcheIler
B. COUNTRY OF BIRTilJ S A
17. MOTHER
A. MAIDEN NAMEEUen J, Me I~
B. COUNTRY OF BIRTilJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
....
:>
<(
c
w -
",u.
Su.
o!<(
z
;;
o
t:
>-
>-
(3
DEATH
o
DEATH
o
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
ffi
<Xl
;:,
::>
z
o
z
<<
>-
w
w
a:
>-
<fJ
1 ST 0 0 1 ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say. that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the marriage state. J.' ~ J I ~
21 SIGNATURE OF GROOM ~ .1.L!.~ IlLJ ~ ~ '....
~ t7 USE ~~E rd'" ""-
DATE 03114/2006
of the bride and groom named above ,by any person authorized by New York Domestic
w York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
e used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
UJ
en
z
UJ
()
::::;
28. PLACE WHERE MARRIAGE OCCURRED
23 SUBSCRIBED AND SWORN TO BEFOR ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Stat
Relations Law ~11 to perform marriage ceremonies within
o If checked, this license is t
24. TOWN OR CITY CLERK
r-^-.
{ } NAME (PRINT)
SEAL .. .g;~A.;tR~
'\ MAILING Aprt 8S
~
TIME
MONTH
YEAR
MONTH
YEAR
11:30 AM
PM 03
15
2006
05
13 2006
STREET
I C~l1TIFY THAT I SOLEMNIZED
THE, MARRIAGE OF THE PER.
SONS NAMED A~OVE ON THE
DI\TE AND AT.1fiETIMIO AND
PLACE INQlC:ATED _'_ . ;.. .
/TOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
AM
PM
ZIP
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
1 D CIVIL
A. STATE NEW YORK B. COUNTY
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
29..0FFICIAt:LT , ";'
NAME (PRllllfl." '.
.~
../:.::.:~ .
. I , ~'
TITLE
SIGNATIJRE ~
MAILING ADDRESS
DATE
SPECIFY
STREET
30. WITNESS TO CEREMONY
CITY/TOWN
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~