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DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Patrick P. Heavev. JR.
MIDDlE CURRENT SURNAME
FIRST
J COUNTY Dutchess
CITYITOWN Wappinger
1368
49
I"
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ma~ret Dibem~~~~~URNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARfllAGE
(OPTIONAL - SEE REVERSE) 105-62 82'''0
D. SOCIAL SECURITY NUMBER - ...
2. RESIDENCE A. t;i~ York d B. __hess
c. CHECK ONE 0 CITY 0 ""TOWN 0 VILLAGE
~~CIFY WappinQer
D. smEET ADDRESS 5 Wildwood Manor Am. 3 A,p 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES O"""NO
3. A. AGE 35 3B.DATEOFBIRTH 11/ 17 / 1Q6
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Heavey
D. scig~l~c~LRi~E:U~~~~RSE) 095-60..0197
12. RESIDENCE A. '1.) York B. 2J#~e9R
c. CHECK ONE 0 CITY 0 ~WN 0 VILLAGE
~~CIFY Wapginger
D. STREET ADDRESS 5 Wildwood Manor Apt 3 AzIP 1 ~S90
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES 0 ~
13. A. AGE "8 13.B. DATE OF BIRTH ~ / DU / 'WiS
14. EMPLOYMENT
A. USUAL OCCUPATION Student
B. ,TYPE OF INDUSTRY OR BUSINESS I Ahman r.:nlIAgA
15. PLACE OF BIRTH (ct':'~lJN-Ny~X1Lr
16. FATHER
A. NAME J8me~ Oibem8ntinn
B. COUNTRY OF BIRTH ( I !::: A
17. MOTHER
A. MAIDEN NAME Mar:garet SJulliwn
B. COUNTRY OF BIRTH I J S 4
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
4. EMPLOYMENT
...
A. USUAL OCCUPATION Steam Fitter
B. TYPE OF INDUSTRY OR BUSINESS local 21
5. PLACE OF BIRTH (t!!f~~T~~
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME Mary MnnrP.
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
o
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u:
II..
C(
Patrick Heavey Sr.
USA
to
DEATH
o
(2) 0 DEATH
DEATH
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE (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
20. IF PREVIOUSLV 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
o
o
o
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 du y sworn, depose a sa'
as to my right to enter into the mar
21. SIGNATURE OF GROOM ~
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23. SUBSCRIBED AND SWORN TO BEFORE M ft ""~R -nn3,
SIGNATURE OF TOWN OR CITY CLERK ~ DATE ~_~~___
This license authorizes the marriage in New York St authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies withi ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl se of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
SIGNATURE ~ -
MAlLIN ADDRESS
~
{ SEAL }
~
TIME
MONTH
YEAR
MONTH
YEAR
AM
02: 1M
04
29
20
Q6
27 2003
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10~
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. CO~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)./ _
o PITY OF 0 TOWN OF ~ VILLAGE OJ.. , J
ECIFY """"P,JCb.t~ ~