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COUNTY Dutchess
CITY/TOWN Wappinger
1368
46
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jeremy C. Herlihv
MIDDLE CURRENT SURNAME
;:1111\11:. riLE: I'IUMDCM
(THIS SPACE FOR STATE USE ONL Y)
DISTRICT
NUMBER
REGISTER
NUMBER
L 0 SUPPLEMENTAL FILE
..J
1. A. FULL NAME
FROM THE BRIDE
11. A. FULL NAME FIRST Mi~~~le Lee Fiq~~!~~URNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Crosse
C. SURNAME AFTER MARRIAGE Herlihy
(OPTIONAL. SEE REVERSE) 324.sn5214
D. SOCIAL SECURITY NUMBER v-
12. RESIDENCE A. N Y B Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY D ~WN D VILLAGE
~~~CIFY WaOPinaer
D. STREET ADDRESS 15 B Scarborouah Lane
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 057.62.3568
D. SOCIAL SECURITY NUMBER
2. RESIDENCE ANY B. Dutchess
c. CHECK ONE (STAg) CITY D ""OWN D VILLAGE (COUNTY)
~~~CIFY Wa~nger
D. STREET ADDRESS 15 B Scarborough Lane ZIP
12590
ZIP 12590
D YES D~O
?Q /1Q7':J
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 29 3B. DATE OF BIRTH 08 /
MONTH
DYES DowINo
19 / 197
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 30 13.B. DATE OF BIRTH OR /
MONTH
4. EMPLOYMENT
14. EMPLOYMENT
Product Anaylst
B. TYPE OF INDUSTRY OR BUSINESS IBM Corp.
5. PLACE OF BIRTH Bronx. New York
(CITY, STATE/COUNTRY IF NOT USA)
A USUAL OCCUPATION Quality Assistant
B. TYPE OF INDUSTRY OR BUSINESS Pepsi Bottling Group
15. PLACE OF BIRTH Blue Island. Cook County. Illinois
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Michael Crosse
B. COUNTRY OF BIRTH USA
17. MOTHER
A. USUAL OCCUPATION
6. FATHER
Kevin Herlihy
B. COUNTRY OF BIRTH USA
A. NAME
7. MOTHER
A. MAIDEN NAME Paula Jenoo
B. COUNTRY OF BIRTH USA
2
Patricia Horgan
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
A. MAIDEN NAME
1 B. NUMBER OF THIS MARRIAGE
W
en
z
W
o
::;j
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) D ~ORCE (3) D ANNULMENT
C. DATE LAST MARRIAGE ENDED? 07/ 31 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? D 1ls D 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
D D 1ST 07/31/1998 Newport News. Virginia D Dol-
D D 2ND D D
D D 3RD D D
D D 4TH D D
edge and belief that the information I provided is true an? that I declare th~t 1 legal impediment eXists
SIGNATURE OF BRIDE ~ ''x\r I ~ J ^ U 91.Q-\A 0 A ~
'T ~ usE CURRENT NAM~
DATE 05l2OI2004
This license authorizes the marriage in New York Stale of I e bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLER~ 25. A. SOLEMNIZATION PERIOD BEGINS
{ , } NAME (PRINT) GIOnaJi .Mo TIME MONTH
SEAL SIGNATURE ~ '. .
'-v-I MAIL~'tlir&lebush Rd, w AM 05
~ ~ ~~
I CERTIFY THAT I SOLEMNIZED ~
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE 1 CIVIL
DATE AND E AND
PLACE I
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 1
DEATH
o
DEATH
o
..
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? W 29 / 1992
MONTH,; DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? D '(ES D 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
(2) D DEATH
1998
YEAR
YEAR
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to the b
as to my right to enter into the ~rriage state.
21. SIGNATURE OF GROO /;
YEAR
28. PLACE WHERE MARRIAGE OCCU~
A. STATE NEW YORK B. COUN~'t"i'lJ#t.'ll
C.
ITY OF /1 TOWN OF D VILLAGE OF
~PECIFY feel ~ ~t.11s J i..
SIGNATURE ~ ~