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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Bq:~ ~IF!. .'r MIDDLE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutchess
CITYrrOWN Wappinger
~tfJ~~t: 1368
~3~~~R 123
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME Erirj!"'ltlln K ean~IDDLE
CURRENT SURNAME
CURRENT SURNAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE .nuYe
(OPTIONAL - SEE REVER~
D. SOCIAL SECURITY NUMBER 093-62 5317
12. RESIDENCE A.N.A~r:k B. D~~I
C. CHECK ONE 0 CITY ii!' TOWN 0 VILLAGE
AND W .
SPECIFY applPger
D. STREET ADDRESf86 Har.ken~ar.k HlF!ight~ ZIP1 '~QO
E. IS RESIDENCE wriHiN LIMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES rll NO
13. A. AGE"" 13.B. DATE OF BIRTH ~ ../... .../..~
~e. '"\lIONTH Oil DAY .9 t ~R
14. EMPLOYMENT
A. USUAL OCCUPATION Teacber
B. TYPE OF INDUSTRY OR BUSINEssArlington Middle Schl
15. PLACE OF BIRTHP~w&~~J$1~ ~f6. Vork
16. FATHER
A. NAMEWilliam Keal"e
B. COUNTRY OF BIRT" J ~ A
17. MOTHER
A. MAIDEN NAME Isabella Theresa Rice
B. COUNTRY OF BIRT" I S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEl..
D. SOCIAL SECURITY NUMBER u;'0-62-7994
2. RESIDENCEA. N~T~O" B. ~ss
C. CHECK ONE 0 CITY otJ TOWN 0 VILLAGE
AND P hk .
SPECIFY ollg eep~le.
D. STREET ADDRESS 16 Hornbeck Road ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES ttJ NO
3. A. AGE33 3B. DATE OF BIRTH M~ /1rly / 'JRl2
4. EMPLOYMENT
A. USUAL OCCUPATION f':ameraman
B. TYPE OF INDUSTRY OR BUSINESS Cablevision
5. PLACE OF BIRTHQueens_ New York
(CITY, STAWCOUNTRY IF NOT USA)
6. FATHER
A. NAME Brian OykIF!. ~r
B. COUNTRY OF BIRTH Wales
7. MOTHER
A. MAIDEN NAME Margaret Breslin
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
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(2) 0 DEATH
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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
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 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
MONTH 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
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
Iment exists
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1ST 0 0 1ST
2ND 0 0 2ND
~ 0 0 ~
4TH 0 0 4TH
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and t
as to my right to enter into the ia~e statn,
21. SIGNATURE OF GROOM ~ 'CJ.
USE CURRENT NA
DATE OQf7Rf7nn;.
by New York Domestic
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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 Sta e of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New 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.
{ ~ } ~:;~;:I:)CJr;~CL~t!~..... . 25. A. SOLEMNIZATION PERIOD BEGINS
SEAL ~G~ru'.~, ~c.:"'. ... _ 0ATI'~Q5 ""'AM MOmH "'"
'-.;-I ~~ Uid~reb ~h Rd, WappiDoerEfll1s, NY 12590 6".00 PM 09 29 2005 11
STREET CI"fTOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27~TYP OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND A' I
PLACE INDICATED. ',3 /0 <;; () S" 9 0 OTHER, SPECIFY
~At.?:i~~~ fJ1<:kI:., (hwc;s f ?3cLt~w TITLE tf.< AeJe;,-
SIGNATURE~ ~~f ~ DATE I~('t'/"~
MAILING ADDREr>~ , It I r~ I rc
II LL-fNTON Sr:. vvllPl1llJGfRS ,-nUS Alv .:l..;)7cJ
STREET cITYrr6wN STATE {-
3D. WITNESS TO CEREMONY
27 2005
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT~tff"s>
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~AGE OF
SPECIFY WI1A'7 ~ F4u-s
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~