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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Daniel Joseph Kiernan
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 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 t ~" I. rJ. _ A If.
21 SIGNATURE OF GROOM ~ - . SIGNATURE OF BRIDE ~ ~~L.-..
23. SUBSCRIBED AND SWORN TO BEFORE ME U E C USE CURRENT NAME 0812412005
SIGNATURE OF TOWN OR CITY CLERK~ DATE
This license authorizes the marriage in New York Stat of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within w York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to e used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CI 25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY Dutchess
CITYrrowlJ w.ppnger
DISTRICT 136&
NUMBER
REGISTER 94
NUMBER
1. A. FULL NAME
MIDDLE
CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
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FIRST
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B BIRTH NAME, IF DIFFERENT
L D SUPPLEMENTAL FILE
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C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEl1Z.:S-ti:l-0643
D. SOCIAL SE~U~ER
2. RESIDENCE A. ark B. Dutchess
(STATE) " (COUNTY)
C. ~~5CK ONWaJirfge.i fDaIS 0 VILLAGE
SPECIFY 61 South R ~
D. STREET ADDRESS ernsen ~enue
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ZIP 12590
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E. IS RE!l)CE WITHIN LIMITS OF CITY OR INCORPORATED 1~GE? 0 YES.Q NO
3. A. AGE 3B. DATE OF BIRTH ,/06 L!974
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Manager
B. TYPE OF IND~RY MSIt~gerrt. Mtg. Compllny
5. PLACE OF BIRTH on . y 0I'k
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER .
A. NAME Joseph James Kiernan
8. COUNTRY OF BIRTH USA
FROM THE BRIDE
11. A. FULL NAME Beth - Anne Tomaskovic
FIRST MIDDLE
CURRENT SURNAME
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7. MOTHER Uncia
A. MAIDEN NAME Anne Richter
B. COUNTRY OF BIRTH U ~ A
B. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVifCE CIVIL A"tiULMENT
D~TH
B. BIRTH NAME (MAIDEN NAME), KiIFFERENT
C. SURNAME AFTER MARRIAGE emsn
(OPTIONAL - SEE REVERSE)088-72-6330
D. SOCIAL SE~~BER
12. RESIDENCE A. ark B. Dutchess
(STATE) .; (COUNTY)
C. ~5CK 'tis I:J CITY Fi=81r 0 VILLAGE
SPECIFY ppngers
D. STREET ADDRESs61 South Remsen Avenue ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A. AGE26 13.B. DATE OF BIRTH 02 .20 1.979
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
8. TYPE OF INDUE&Y OR e1U~ Un - Employed
15. PLACE OF BIRTH rm. VOl1C
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A NAME John Michael Tomaslmvic
B: COUNTRY OF BIRT)J SA
17. MOTHER
A. MAIDEN NAME Dolores Eileen Barthen
B. COUNTRY OF B~)J SA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D'CfRCE CIVIL A'aULMENT
DtiTH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
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
~
{ SEAL}
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YEAR
10
23 2005
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
ZIP
STATE
27. TYPE OF CEREMONY
o ~IGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE r:-fU~./
A. STATE NEW YORK . ~~
C. LOCATION OF CEREMONY
(CHECK ONE ~ND7CIFY)
o CITY OF eTOWN OF 0
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C. DATE LAST MARRIAGE ENDED?
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
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NAME (PRINT)
STREET CITYITOWN
~~~R~:Ri~~~ IO~O~~~N~:~ 26. SOLEMNIZATION OCCURRED
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR
DATE AND AT THE TIME AND A
PLACE INDICATED. -3 M
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29'OFFICIANT~..m t '.~~CV-IC.'
NAME(PRINT)_ _.' "
SIGNATURE~' ~
MAl ING ADDRE /" ~ A . . /
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STREET
30. WITNESS TO CER MONY
NAME (PRINT) C I
NAME (PRINT)
SIGNATURE ~