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N
COUNTY
CITYrrOWN
DISTRICT
NUMBER
REGISTER
NUMBER
n. Jtt".h~~
WaJ"PiogP-f
1366
'30
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
tilAl1: riLl: NUMtU:M
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
J,~ K. 0' Ha~nlT SURNAME
1. A. FULL NAME
MIDDl~an FiQ~URRENT SURNAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE F'I~a
(OPTIONAL. SEE REVERSE) ~
D. SDCIAL SECURITY NUMBER 055 618660
B. ~ess
o VILLAGE
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER
089-66-5672
B (~esE
VILLAGE
12. RESIDENCE A. II.J V
nrS~TE)
C. ~~5CK ONE 0 CITY 0 ~WN
SPECIFY p..oughkeepsie
D. STREET ADDRESS 7 Jay Road ZIP 12603
E. is RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES D~O
13. A. AGE 28 13.B. DATE OF BIRTH MOQJ / Q2 /1$HJ3
14. EMPLOYMENT
2. RESIDENCE A IIJ V
. (STitrEl
C. ~~5CK ONE 0 CITY o..;rOWN 0
SPECIFY Poughkeep$ie-
D. STREET ADDRESS 7 lev Road
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
38. DATE OF BIRTH
ZIP
o
3. A. AGE 29
4. EMPLOYMENT
A. USUAL OCCUPATION Sales
A. USUAL OCCUPATION ReceptiQnist
B. TYPE OF INDUSTRY OR BUSINESS \^Japp. Falls Toyota
15. PLACE OF BIRTH (MM.b.~~~J;grl<
16. FATHER
A. NAME John 0 I Hanlon
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Louise Antle
B. COUNTRY OF BIRTH U S ^
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
l-
S;
<t
C
u::
u.
<t
B. TYPE OF INDUSTRY OR BUSINESS Self-employed
5. PLACE OF BIRTH (fHtt~fp~ Yorl<
6. FATHER
A NAME Nathan stuart Figa
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Patriola !\An TloIllipano
8. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
(3) 0 ANNULMENT
/ /
DEATH
o
(2) 0 DEATH
o g
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOLlSE(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
C. DATE LAST MARRIAGE ENDED?
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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, tha
as to my right to enter into the marria
21. SIGNATURE OF GROOM ~
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
y knowledge and belief that the information I provided is true and that I declare that no I gal impediment exists
w
en
z
w
o
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23. SUBSCRIBED AND SWORN TO BEFORE ME
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
DATE
by New York Domestic
~
{ SEAL }
'-..t-'
YEAR
MONTH YEAR
TIME
MONTH
04
17
2
06 15 2004
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNTY QR.lttlJ(, (
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF r D? VILLAGE OF
SPECIFY Nw WtlV,O 50~
o 0 RELIGIOUS 1 0 CIVIL
9 t;l( OTHER, SPECIFY fYlAiJ(fJ..1l}
NAME (PRINT)
SIGNATURE ~