034
STATE OF NEW YORK I STATE FILE NUMBER I
::I ~ (THIS SPACE FOR STATE USE ONLY)
COUNT'( DEPARTMENT OF HEALTH
, CITY/TOWN W8pp1n~r
DISTRICT 1~ AFFIDAVIT, LICENSE and
NUMBER
~Q~~l~R M CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME ElfriD J O' Cotlml,. SURNAME 11. A. FULL NAME JSIlhryn Hea!MRRENT SURNAME
FIRST FIRST
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
O. SOCIAL SECURITY NUMBER Q8&.6O. 3257
2. RESIDENCE A.~)yOr:lc B. -QMl~_
C. CHECK ONE 0 CITY 0 TOWN [M'VILLAGE
~~~CIFY ~ppngem Falls
D STREET ADDRESS ?1 FrsnldintfRl~ ~v~n'l~ "ptIP 12590
E. IS RESIDENCE WITHI:CIMITS OF CITY OR INCORPORATED VILLAGE? Q;YES 0 NO
Moo1~ / OJ / vt;964
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE O' CaAAar
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 068 58..5190
12. RESIDENCE A. NMEycnk B. ~ess
C. ~~5CK ONE 0 CITY 0 TOWN D,Jr'ILLAGE
SPECIFY "'lappiAge" Falls
D. STREET ADDRESS 21 Fr.ankliRdale .4.\'enue AplZIP 12580
E. IS RESIDENCE WITHIN'UMITS OF CITY OR INCORPORATED VILLAGE? ~YES 0 NO
13. A. AGE 42 13.B. DATE OF BIRTH McOS / 1:) ~B1
14. EMPLOYMENT
A. USUAL OCCUPATION Meat VVFapper
B. TYPE OF INDUSTRY OR BUSINESS HanAGferd's
15. PLACE OF BIRTH ra~ Y.SA)
16. FATHER
A. NAME James JBBeph Healy
B. COUNTRY OF BIRTH U S 1'.
17. MOTHER
A. MAIDEN NAME Katherine r1anegan
B. COUNTRY OF BIRTH USA
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
3. A. AGE 39
4. EMPLOYMENT
A. USUAL OCCUPATION Roofer
B. TYPE OF INDUSTRY OR BUSINESS Self Employed
5. PLACEOFBIRTH~N.Yofk
6. FATHER
3B. DATE OF BIRTH
A. NAME James O' CGnnar
B. COUNTRY OF BIRTH Ireland
7. MOTHER
A. MAIDEN NAME Mal)' Jean Fatty
B. COUNTRY OF BIRTH IrellRel
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
DEATH
DEATH
o
(2) 0 DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
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(2) 0 DEATH
(3) 0 ANNULMENT
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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 S te of the bride and groom named above by any person authorized by New York
Relations Law ~11 to perform marriage ceremonies wit New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license i 0 be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
Domestic
~
{ SEAL }
'-v-/
NAME (PRINT)
TIME
MONTH
YEAR
MONTH
YEAR
AM
PM
04 24 06 22 2004
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY i:L.kJu~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LLAGE OF
SPECIFY Wa, Pf inJ tr.s Fa if t)
ZIP
11!1"'CIVIL
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