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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
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STATE FILE NUMBER
(THIS SPACE FOR STATE USEONLY)
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Dutchess
COUNTY WI~nyer
CITYrroY"r388
DISTRICT
~~~~~~R 93
NUMBER
L 0 SUPPLEMENTAL FILE
~
1. A. FULL NAME
Christi~P€l~Wih.&-
11. A. FULL NAME
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
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B. BIRTH NAME (MAIDEN NAME), GIf.~
C. SURNAME AFTER MARRIAGE ~
(OPTIONAL - SEE REVERSE)Y' "-ut.r~
D. SDCIAL SEIlIiI'. ~
12. RESIDENCE A. (STATE) '" B. (COUNTY)
C. CHECK O_.~~TOWN 0 VILLAGE
AND rUUWI~V
SPECIFY 15 GouIh Geto DrIve
D. STREET ADDRESS
.;
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE 1~
(OPTIONAL - SEE REVERSE) UU"'V'rO' 19
o SOCIAL SE~'&k Dutchess
2. RESIDENCE A. '(STATE)"; B. (COUNTY)
C. ~~gCK ONWnsidlfi 0 TOWN 0 VILLAGE
SPECIFY 9 V.tite Farm Road
D. STREET ADDRESS ZIP
E. IS RE~CE WITHIN LIMITS OF CITY OR INCORPORATEDm-'GE? .ndJ
3. A. AGE 3B. DATE OF BIRTH ~
MONTH DAY
4. EMPLOYMENT
12594
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E. IS RE~CE WITHIN LIMITS OF CITY OR INCORPORAT1'O'ILLAGE~1 0
13. A. AGE 13.B. DATE OF BIRTH -
MONTH DAY
14. EMPLOYMENT
~NO
YEAR
YES~
/l:t/:t
YEAR
supervtsor
A. USUAL OCCUPATION Helidllr Bawl
B. TYPE OF IND~e, N&\":York
15. PLACE OF BIRTH
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER James SkBpeIis
A. NAME USA
B. COUNTRY OF BIRTH
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NBIIanaI Air Guard
,.~.~ N. Y. A N. G.
B. TYPE OF INDUlK~SlNiSS,. "101.....
....'nIClll, -I......... J "
5. PLACE OF BIRTH
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER Clarence Gallagher
A. NAME USA
B. COUNTRY OF BIRTH
A. USUAL OCCUPATION
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Deborah Ann Cleary
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH 1
18. NUMBER OF THIS MARRIAGE
17. MOTHER
7. MOTHER Diane Napolitano
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH 1
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV'aCE CIVIL AN~LMENT
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIQ'RCE CIVIL A"tJ.lLMENT
DEtfH
DE(JH
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
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 ANNULlED, 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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1ST
2ND
3RD
4TH
I, being duly sworn, depose and sa
as to my right to enter into the marri
21. SIGNATURE OF GROOM ~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
wledge and belief that the information I provided is tr
. SIGNATURE OF BRIDE ~
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York Sta person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within ew 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 CI~C. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) ~ ~ . oar>>I2OD5
SEAL ~..~~~pJi,.,.. F"I5, M 1S
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STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27;;ZTYP OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE 0 RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~~T~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF I ~I TOW~ OF ~f: OF
SPECIFY villtPf'll"6'FR. S 1tl.LS
NAME (PRINT)
SIGNATURE ~
SIGNATURE ~
DOH.9B 111/98)