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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
COUNTY O. dr.he!':!':
CITYITOWN Wappinger
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~5~I:l~R 64
1 A. FUll NAME
Mir.hael Anthn~ Glee~nn
FIRST MI lE
CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
0-
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1n5-~n.."7R1
D. SDCIAl SECURITY NUMBER _ _~~~:1___
2 RESIDENCE A. N Y B. O. dr.he~!':
(STATE) ~)
C. CHECK ONE 0 CITY 0 TOWN tI VILLAGE
~~~CIFY Wappingers Falls
D STREET ADDRESS 10 North Remsen Avenue ZIP 1'590
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3 A. AGE 34 38. DATE OF BIRTH Mol-1 / ll~ / 19lO
4. EMPLOYMENT
A. USUAL OCCUPATION Pet Shop Owner
B. TYPE OF INDUSTRY OR BUSINESS ~elf_emplnyed
5. PLACE OF BIRTH ManhAtbm NAW York
(CITY. ST A TElCOUN'rRY IF NOT USA)
6. FATHER
A. NAME Frank Gleeson
8. COUNTRY OF BIRTH I ) ~ A
7. MOTHER
A MAIDEN NAME Edith Daly
8. COUNTRY OF BIRTH l' ~ A
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
L 0 SUPPLEMENTAL FILE
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FROM THE BRIDE
11. A. FULL NAME ~lir.iA Nir.ol~ Pinp.
FIRST MIDDLE
CURRENT SURNAME
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
c. S~~~~JN~~~~~t:~~~SE~lee5on
D. SDCIAl SECURITY NUMBER 1 :\'-7O-A&16
12. RESIDENCE A. N 'tTATE) B D'!t~s~
C. CHECK ONE 0 CITY 0 TOWN rsf VILLAGE
~~~CIFY Wappingers Falls
D STREET ADDRESS 1 n North Remsen Avenue ZIP 1 '~Qn
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
13. A. AGE 28 13.B. DATE OF BIRTH ~TH --1~AY 'Hi7JAR
14. EMPLOYMENT
A. USUAL OCCUPATION Managar
B. TYPE OF INDUSTRY OR BUSINESS Verilon Wirele5s
15. PLACE OF BIRTH ~.!iWSf.~~~A)
16. FATHER
A. NAME Rohert Frederir.k Pine
B. COUNTRY OF BIRTHI. S f1.
17. MOTHER
A. MAIDEN NAME Nancy Ann Bacon
B. COUNTRY OF BIRTH)) SA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
DEATH
n
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(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
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
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
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o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
f my knowledge and belief that the information I provided is true ana-n,at
23. SUBSCRIBED AND SWORN TO BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State 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.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
21.
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{ } NAME (PRINT)
SEAL SIGNATURE ~
'-v-I MA~~UdR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
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DATE
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
ZIP
11 :16 ~~ 07
14
2005
09
11 2005
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ()\rQ..v\1
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY '(\ e'.-W t~~ ,.~('
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