191
STATE OF NEW YORK r- STATE ALE NUMBER I
:1 (THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess DEPARTMENT OF HEALTH ., la- ~ c - 0 ~
CITYITOWN Wappinger ~
DISTRICT 1368 AFFIDAVIT, LICENSE and
NUMBER
REGISTER 191 CERTIFICATE OF
NUMBER
MARRIAGE Lo SUPPLEMENTAL FILE -.J
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME Thomas A Gallman 11. A. FULL NAME Kerrv L. Gallaaher
FIRST MIDDLE CURRENT SURNAME ARST MIDDLE CORRENT SURNAME
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2ND D D 2ND D D
3RD D D 3RD D D
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I, being duly sworn, depose and say, that to the bes of my knowledge and belief that the information I provided is tru7Led that I declare that no legal impediment exists
as to my right to enter into the marria t . 11 . J! /I ....,
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~ fVI.J 'a):..Jt./JC2i1.A 1 -
I U~CURRENT NAME L - -
23 ~::J:,.~~~DO~N-?o~~~~ cir'ivBg~~~~E DATE 1 ') 119/7nn7
This license authorizes the marriage in New York St of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D 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
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) lOr:-. 66-4104
O. SOCIAL SECURITY NUMBER ':;-)-
2. RESIOENCEA. &imf York B. (cPuMtfhess
c. CHECK ONE D CITY D TOWN D 'tfLLAGE
~~CIFY Wappingers Falls
D. STREET ADDRESS 76 Carmine Orive Unit O'13lp '12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? D ~S D NO
3B. DATE OF BIRTH
3. A. AGE 22
4. EMPLOYMENT
A. USUAL OCCUPATION Fnuimnmental Servir.e~
B. TYPE OF INDUSTRY OR BUSINESS ~p.vp.rn Trp.nf Fnvir ~p.r
5. PLACE OF BIRTH (CX~~:wm"IM~sXnrk
6. FATHER
A. NAME Rir..h1ud ~sllm~:m
B. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A. MAIDEN NAME Mary~nn Turner
B. COUNTRY OF BIRTH l' 5 A
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
DEATH
n
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
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NAME (PRINT)
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Gallm an
D. sJ~~II~cA~R;~E~U~~~~RSE) 050-74-0603
12. RESIDENCEA. ~~ York B. (Po~~)hess
c. CHECK ONE D CITY D TOWN D vlLAGE
~~CIFY Wappingers Falls
D. STREET ADDRESS 76 Carmine Drive Unit D'l~p '12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? D ~S D NO
13. A. AGE 23 13.B. DATE OF BIRTH 11 / 12 / 1979
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Rp.r.rp.!'!tian nirp.r.tor
B. TYPE OF INDUSTRY OR BUSINESS nmm Hilt A~~nr.iRfp.!'l
15. PLACE OF BIRTH MnJJnt Ki~r.n Np.w Ynl*
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Peter Gallagher
B. COUNTRY OF BIRTH t I ~ A
17. MOTHER
A. MAIDEN NAME Katherine Cole
B. COUNTRY OF BIRTH [I S A
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
DEATH
n
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
TIME
YEAR
MONTH
DAY
MONTH
YEAR
ZIP
10:~
PM
12
20
20 2 02
17 2003
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TA E
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 D OTHER, SPECIFY
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 1;j~cJ.. tsT'(.(
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF D TOWN OF D VILLAGE OF
SPECIFY f'J..PJt [sf/il
TITLE
NAME (PRINT)
SIGNATURE ~
DOH-9B (11/9B)
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/2./.J./ /6^-
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31. WITNESS TO CE
NAME (PRINT)
SIGNATURE ~