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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ryan C. Banda
MIDDLE CURRENT SURNAME
COUNTPutchess
CITYiTowJf!appinger
~~J~~cR1368
~G~~;~"3
1. A. FULL NAME
FIRST
a..
N
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSIiI42 62 6379
o SOCIAL SECURITY NUMBER I - -
2 RESIDENCE ANew York B. Dutchess
(STATE) J (COUNTY)
C. CHECK ONE 0 CITY"" 0 TOWN 0 VILLAGE
~~~CIFY Wappinger
o STREET ADDREss17 Martin Drive
4. EMPLOYMENT
A USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESJ,Jnemployed
5. PLACE OF BIRT~OrristOwn. New Jersey
(CITY, STATE/COUNTRY IF NOT USA)
ZIP 12590
o YES"'b NO
/1975
YEAR
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AG2.7 38. DATE OF BIRTH 03 A1
MONTH DAY
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6. FATHER
A NAME Robert Banda
B. COUNTRY OF BIRTJJ S A
7. MOTHER
A MAIDEN NAME Dorothy Brower
B. COUNTRY OF BIRTHU SA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW 010 LAST MARRIAGE END? (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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,
as to my right to enter into the marri
21. SIGNATURE OF GROOM ~
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
"I
~tj'
7 .J.3 '11
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Shannon J. Mc Elroy
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Banda
(OPTIONAL - SEE REVERSEft52 56-0944
D. SOCIAL SECURITY NUMBER U -
12. RESIDENCE ,New York BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY tJ TOWN 0 VILLAGE
AND \AI .
SPEClp,oW. applnger
o STREET ADDRESSl7 Martin Drive
ZIP12590
o YES....O NO
'W74
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A AGrJ.7 13.B. DATE OF BIRTH 12 ..l1
MONTH DA Y
14. EMPLOYMENT
A USUAL OCCUPATIONTeacher
B. TYPE OF INDUSTRY OR BUSINESs\'Vappinaers Central School
15 PLACE OF BIRTPouahkeepsie:New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A NAM~ames Mc Elroy
B. COUNTRY OF BIRTU S A
17. MOTHER
A MAIDEN NAMEJudith Reichard
8. COUNTRY OF BIRTU S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
8. HOW 010 LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(31 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DA Y YEAR
D. ARE ANY FORMER SPOUSE(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
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
and belief that the information I provided is true and
o
o
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22. SIGNATURE OF BRIDE ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York
Relations Law ~11 to perform marriage ceremonies wit 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
{ } NAME (PRINT) Gloria J.
TIME MONTH YEAR
SEAL SIGNATURE ~ DATJJ5/30/2002
'-,,-I ~bl~t~me Su er Falls NY 12590
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
MONTH
YEAR
ZIP
AM 05
2:14 PM
29 2002
31
2002 07
STATE
27. TYPJ-OF CEREMONY
o ~ElIGIOUS 1 0 CIVIL
9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
TITLE
DATE
/l1,
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~:?
IE, C. fi:'/:st
7/t;:fQ/~L
. I:<S<JtJ
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /'
o CITY OF ~ TOWN?F iiYVILL~ OF
SPECIFY 'Ai'P/IV~,2.S I-(1U.S
ATE
NAME (PRINT)
SIGNATURE ~