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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael C Bannon
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYITOWN Wappinger
~5'J:~c~ 1368
~5~\fJ~R 38
1. A. FULL NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 051 "0.5108
D. SOCIAL SECURITY NUMBER __ -L-___
2. RESIDENCE A. N v B. . nlltm ..
(l-tATE) ~
C. CHECK ONE 0 CITY WI! TOWN 0 VILLAGE
AND c-uooh~
SPECIFY r......-~e
D. STREET ADDRESS 11 Cerci... DrIve ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES P!f NO
Mc94 / ~ /11f12
3. A. AGE 30
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Correctian Officer
B. TYPE OF INDUSTRY OR BUSINESS Putnlim Caunty
5. PLACE OF BIRTH ~At~U~Yark
6. FATHER
A. NAME Charles Francis Bannan. III
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Bemer. 1.ynt'A Singer
B. 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
DEATH
o
(2) 0 DEATH
B. HOW 010 LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
YEAR
MONTH DAY
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
:nATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
..~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
--1
CMriIvn A Janes
FIRST - Miiioi]" - - CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT M~
C. SURNAME AFTER MARRIAGE B8nnon
(OPTIONAL - SEE REVERSE) 117' ~5455
D. SOCIAL SECURITY NUMBER _ __~_-
12. RESIDENCE A. N lTATE) B. ~
C. CHECK ONE 0 CITY !Y'TOWN 0 VILLAGE
AND 0-. .......a.-i...
SPECIFY r.....~
D. STREET ADDRESS 11;.. CercI... DrIve ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
AGE 28 13.B. DATE OF BIRTH M~H /~Y .J(~~
11. A. FULL NAME
13. A.
14. EMPLOYMENT
A. USUAL OCCUPATION Car Sales
B. TYPE OF INDUSTRY OR BUSINESS 11..81 Bros.
15. PLACE OF BIRTH YOItctawn New York
(CITY, STATE/CO~NTRY IF NOT USA)
16. FATHER
A. NAME Richard T. M~
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME UndII ~ F=errn
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS' MARRIAGE 2
o
o
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) c1'DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 10 / 18 /1999
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
1B11811AAA Klno"un, N8w Vtvk'
DEATH
o
r!!
o
o 0
o 0
o 0
pediment exists
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, th
as to my right to enter into the marri
21. SIGNATURE OFGROOM ~ .,'
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State 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.
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
o
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en
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{ SEAL }
'-v-I
SIGNATURE ~
MAILING AqDRESS
ATE
by New York Domestic
TIME
MONTH
YEAR
DATE 04I1QQ0D3
AM
12:29PM 04
2B. PLACE WHERE MARRIAGE OCCURRED
ZIP
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TATE
27. TYPE OF CEREMONY
o)t RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
A. STATE NEW YORK B. COUNTY a....~~e..
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
SPECIFY N-evJ k,/,t-"ot~,...
TITLE ()rJ.0~c/ Cf~<t/"?PV-"
DATE c?,-//j.t~3
NY /2, 'f'?
I
26. SOLEMNIZATION OCCURRED
TI E MO. DAY YEAR
1/,'30 AM () 'I :l. G 03
~~~:j~~~~ 1(0...,.. L 6~ O.s;ge---1
SIGNATURE~ '7'0,.). /~ A ~~~
MAILING ADDRESS
3.13MA'f.-' t'7: SA..cf",,~7:eJ
STREET CITYIT~WN
30. WITNESS TO CEREMONY
rt.L(/fM r: I//lc;~
.~
STATE
NAME (PRINT)
SIGNATURE ~
