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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Donald C Rmwn
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYiTOWN WaDDinger
~~J~~crJ 1368
~5~~J~R 109
1. A. FULL NAME
FIRST
..
N
8. BIRTH NAME, IF DIFFERENT
c. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 11 g..t::.t:!!o .1135
D. SDCIAL SECURITY NUMBER - - -~--
2. RESIDENCE A. N Y B. nlltMAac.
(STATE) ~
C. CHECK ONE 0 CITY f'1! TOWN 0 VILLAGE
~~~CIFY East FIShIdlI
D. STREET ADDRESS 27 Peters R08d
3. A. AGE 30
ZIP 12533
YES rt/ NO
/ 1913
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
MO~ / Q!$
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Delivery
8. TYPE OF INDUSTRY OR BUSINESS Self Employed
5. PLACE OF BIRTH Pouahk8eDsle. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Jeffery A Brallvn
8. COUNTRY OF BIRTH Unknown
7. MOTHER
A. MAIDEN NAME Georgina M. Berger
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
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
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~Ie GallaMENT SURNAME
11. A. FULL NAME
FIRST
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE -~
(OPTIONAL - SEE REVERSEf""
D SDCIAL SECURITY NUMBER 103 66 5384
12. RESIDENCE A. N ~ATE) B. ~
C. CHECK ONE 0 CITY ~TOWN 0 VILLAGE
~~~CIFY East FISbIciIl
D. STREET ADDRESS 27 Peters Road ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 23 13.8. DATE OF BIRTH Jt1H /16y 19BC
14. EMPLOYMENT
A. USUAL OCCUPATION Housewife
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH ~~~~ Yor.k
16. FATHER
A. NAME I(AftNIJIth Richard Gallagher
8. COUNTRY OF BIRTH II S A
17. MOTHER
A. MAIDEN NAME .JaR Marcia FeRler
B. COUNTRY OF BIRTHU SA
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
DEATH
o
o
(2) 0 DEATH
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
2D. 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
YEAR
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o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
owledge and belief that the information I provided.
o 0
o 0
o 0
o 0
e and that I declare that no legal impediment exists
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Sta of 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.
. 0 If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLI~RK 25. A. SOLEMNIZATION PERIOD BEGINS
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DATE nR/11/2003
by New York Domestic
TIME
MONTH
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
YEAR
MONTH
DAY
YEAR
DATE 08111/2003
n r Falls NY 12590
CITY /TOWN ST A E
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
..,;,:.=
.25 AM 08
PM
12
2003 10
10 2003
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A STATE NEW YORK B. COU~r'j' E :;. f
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
1I..ti~/j 1..' /'1
SPECIFYPqt-r1y/if .
STATE