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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
M.~G ~~
~ S M DO
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 07 / 1? / 1~1
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? !'tYES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 07/12/1991 Esc-mble Com1ly. FlorI~
~ 0 0 ~
3RD 0 0 3RD
~ 0 0 ~
I, being duly sworn, depose and s ,that to the best of my knowiedge and belief that the information I provided is true and that I
as to my right to enter into the ma~ age staty . ~ . .
21. SIGNATURE OF GROOM ~ ~ 22. SIG :<>.TURE OF BRIO
us
COUNTY Olltcbess
CITYiTOWN Wappinger
~~~:~c~ 1368
REGISTER 142
NUMBER
1. A. FULL NAME.
CURRENT SURNAME
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER On.3O-R163
2. RESIDENCE A. ~T'tOlk B. ~
C. CHECK ONE 0 CITY t/tJ TOWN 0 VILLAGE
AND
SPECIFY SomAnI
o STREET ADDRESS ~ A Heritage I-III~ ZIP 105fm
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 7-4 3B. DATE OF BIRTH ftD / "'D /4 0'a4
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4. EMPLOYMENT
A. USUAL OCCUPATION Relim.
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH ~ ~
, :AT NOT USA)
6. FATHER
A. NAME Mi~ I+-~
B. COUNTRY OF BIRTH Ireland
7. MOTHER
A. MAIDEN NAME A;r.- M~ QahllA
B. COUNTRY OF BIRTH Ireland
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) r!! DEATH
C. DATE LAST MARRIAGE ENDED? 02 / 1~ /1QQ')
MONTH D1r y~
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES ~ NO
10. IF PREVIOUSLY DIVORCED OR ANNUlED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
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11. A. FULL NAME .Ianp- R~
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Wndbeim
c. SURNAME AFTER MARRIAGE a...a.adv
(OPTIONAL - SEE REVERS1:)~1 ftr P.... ..........g
D. SOCIAL SECURITY NUMBER -~~~
12. RESIDENCE A.~ B. J:gmra
c. CHECK ONE II!!! CITY 0 TOWN 0 VilLAGE
AND p'___--I
SPECIFY ~8
D. STREET ADDRES~ Lagan Drive ZIP~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE-48 13.B. DATE OF BIRTH nR .(3 ~95Z
-----mNTH DAY , YEAR
CURRENT SURNAME
14. EMPLOYMENT
A. USUAL OCCUPATION Un-emplflYed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTHP",It'IhIt.-ncl", f\J8WYork
(~~Y If NOT USA)
16. FATHER
A. NAMEAlfred ~~ Wndheim
B. COUNTRY OF BIRTi-U S A
17. MOTHER
A. MAIDEN NAME Anna Marie Bany
B. COUNTRY OF BIRT'" I S 1t
lB. NUMBER OF THIS MARRIAGE 2
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license - authorizes the marriage in New York State
Relations Law ~11 to perform marriage ceremonies within Ne 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL }
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NAME (PRINT)
TIME
MONTH
YEAR
MONTH
YEAR
DATE 11nmoos
AM
12:19 PM 11
22 2008
24
2005
01
ZIP
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TYPE OF CEREMONY
o Ii""'RELlGIOUS
9 0 OTHER, SPECIFY
1 0 CIVil
A. STATE NEW YORK B. COUNTY Oil 1:/-//Ec;S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF V'!'OWN OF 0 VilLAGE OF
29. OFFICIANT ,.:J ,');) i IE N /'IE
NAME (PRINT) rlL,,/,n -
TITLE
28. PLACE WHERE MARRIAGE OCCURRED
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DATE SPECIFy.EIISr f/6/1K/tJ...
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S ATE ZIP
31. WITNESS TO CE~ONY
NAME (PRINT) _ PrUv CMp--
SIGNATURE ~ ( 1111..Q <!.<R 17 J'\...