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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brian Keane
I
STAT!: f'1L.t:. NUMDcn
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY Dutchess
CITYfTOyt W8~nger
DISTRICT 368
NUMBER
REGISTER 14
NUMBER
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME Carol Jean Leone
FIRST MIDDLE
CURRENT SURNAME
11. A.
FIRST
MIDDLE
CURRENT SURNAME
D.
N
B. BIRTH NAME (MAIDEN NAME), f(lIFFERENT
C. SURNAME AFTER MARRIAGE eane - Leone
(OPTIONAL - SEE REVERSE)024-48-5983
D. SOCIAL SEMA" NUMBER
12. RESIDENCE A. B. Suffolk
(STQIE) (COUNTY)
C. CHECK o~_-<._g CITY 0 TOWN 0 VILLAGE
AND tKJ5IDn
SPECIFY
D. STREET ADDRESS 190 B Sydney street
Zlp021~
DYES"; NO
1~
DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE09"J-t:)"L-4901
D. SOCIAL SEC.lJlN,Y NUMBER
2. RESIDENCE A. MA B. Suffolk
~ST. E) (COUNTY)
C. CHECK ON CITY 0 TOWN 0 VILLAGE
AND
SPECIFY 1
o STREET ADDRESS 90 B Sydhey street ZIP 02125
E. IS RE!8NCE WITHIN LIMITS OF CITY OR INCORPORATEDcirGE? ~ YES .Q9Ef7
3. A. AGE 3B. DATE OF BIRTH /05 L!
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Attorney
B. TYPE OF IND1i~.m!'ll-lSI~i~. ~~an Bond Group
5. PLACE OF BIRTH rggff,J)'n, rtWW V 0I'k
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER \IWI .
A. NAME IlIam Keane
B. COUNTRY OF BIRTH USA
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE36 13.B. DATE OF BIRTH 04 ~
MONTH
14. EMPLOYMENT .
A. USUAL OCCUPATION Engineer
B. TYPE OF IND~~USIN'" vel'l%on COmm.
15. PLACE OF BIRTH rg, assacnuseltS
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER Sa Leone .
A. NAME m
B. COUNTRY OF BIRTHU S A
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17. MOTHER
A. MAIDEN NAME Ellen Butler
B. COUNTRY OF B~ SA
1 B. NUMBER OF THIS MARRIAGE 1
7. MOTHER
A. MAIDEN NAME Isabella Rice
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVrCE CIVIL A"6ULMENT
.;
B. HOW DID LAST MARRIAGE END? (3) 0 DIV01j8 (3) ~NULMENT2Ci)i DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONT.,- DAY YEAR
D. . ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
~)cant6nAtf8SS8Ci\~ S::t SPOUSE
1ST ' 0 0 1ST
~ 0 0 ~
~ 0 0 ~
~ 0 0 ~
I, being duly sworn, depose and say, that owledge and belief that the information I provid
as to my right to enter into the marriage te
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D'60RCE CIVIL A~ULMENT
Dl$TH
D~TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULEO, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
YEAR
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21. SIGNATURE OF GROOM ~
23.
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
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TIME
MONTH
YEAR
MONTH
YEAR
NAME (PRINT)
SIGNATURE ~
M2(')J
DATE 0310312006
ppinger Falls, NY 12590
02 2006
AM 03
:16 PM
04
2006
05
ZIP
STATE
27. TYPE OF CEREMONY
1 rI CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~
C. LOCATION OF CEREMONY
(CHECK ONE A~ SPECIFY)
o CITY OF "TOWN OF 0
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
SPECIFY