059
]
0
.q
m
0
or-
.:%
L..
~ ill
~
...... <<
5- ~
if>
(Ii
Z
~
..- I-
~
(j)I;J) :>
I~~
~_jLL
Z<>>><C
Q>~
~ 0
:u !:
Ul ~
6>- u
WL..
a::J
~
~
U
~
~
>=
a:
ill
U
UJ
G:
UJ
I
;;=
Ul
Ul
UJ
G:
o
o
<<
i::
u
ill
"-
Ul
5
m
"
:i?
o
z
<<
~
ill
ill
a:
~
if>
z:tz
2~g
ill <
a:"'N
r-ffiz
Ul-,:2
:::lOW
~"O
>-ZUl
z-
~~LL
OUlO
~OU)
0>->-
w~C3
b~~
Z::::J~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Daniel T. Gorman
COUNT,Qutchess
CIT'Y'~TOWN Wappinger
~~~~~CR1'J 368
~G~lmP59
A FUll NAME
FIRST
MIDDLE
CURRENT SURNAME
"-
N
BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
,OPTIONAL SEE REVERS!ft89-72 1570
o SOCIAL SECURITY NUMBER U -
2. RESIDENCE ANew York B. Oranae
(S;;;:TE( (COUNfY(
C CHECK ONE [] CITY 0 TOWN 0 VILLAGE
~~~CIFY Middletown
STREET ADDRESS 10 Canterbury Drive ZIP 10940
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE' "D YES 0 NO
/20 /1977
DAY YEAR
3. A
AGE24
3B. DATE OF BIRTH
08
MONTH
4 EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINEssOrange County Comm.
5 PLACE OF BIRTJ3ronx New York"
(CITY. S1ATEiCOUNTRY IF NOT USA)
6 FATHER
A. NAME Lawrence Gorman
B. COUNTRY OF BIRTHU S A
7 MOTHER
A. MAIDEN NAME KRthlp.p.n FRrTp.1I
B. COUNTRY OF BIRTH England
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 DID LAST MARRIAGE END' (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) LJ ANNULMENT
/ /
(2) 0 DEATH
MONTH DA Y YEAR
o 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)
I
dJ~t b
.." (7
!J ~C):1\
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Allysha M. Bomba
MIDDLE CURRENT SURNAME
~
11 A FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C SURNAME AFTER MARRIAGE Gorman
(OPTIONAL. SEE REVERSE"'67 85-4745
D SDCIAl SECURITY NUMBER i!. -
12 RESIDENCE ANew York BDutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~ClFyWappinqer
STREET ADDREss11 Liss Road
ZIP 12590
o YES~ NO
1fI7R
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE'
13 A. AGF23 13.B. DATE OF BIRTH OR /1'9
MONTH DAY
14. EMPLOYMENT
A USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Tutor Time Learning
15. PLACE OF BIRTrPasco CounfV: Florida
(CITY. STATE'couNT'RtrF NOT USA)
16. FATHER
A NAMEStanley Bomba
B COUNTRY OF BIRTU S A
17. MOTHER
A. MAIDEN NAMECarol Hayter
B. 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
B. HOW DID lAST MARRIAGE END' (3) 0 DIVORCE
C DATE lAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2( 0 DEATH
MONTH DA Y YEAR
o 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
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNA TURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St anG 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.
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) Glo .
...-
21 SIGNATURE OF GROOM ~
w
(/)
Z
W
U
...J
~
{ SEAL }
'-.,-I
SIGNATURE ~
MAILING ADDRESS
20 Middlebush Rd
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
26. SOLEMNIZATION OCCURRED
TIME MO DAY YEAR
...
PM
29 OFFICIANT
NAME (PRINT)
0 C'
0 0
[]
D
. SIGNATURE OF BRIDE ~
TIME
MONTH
MONTH
YEAR
YEAR
1 :52 AM
PM 05
16
2002 07
14 2002
ZIP
I~CIVIL
28 PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTyA4.J1~L1
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
[; CITY OF ~TOWN OF 0 VILLAGE OF
SPECIFY~l.Al 'if A
ZIP
31 WITNESS TO CEREMONY
Sha^~~f\ ~r-htr~c &....
SIGNATURE~ ~. ___ &,/,.hL....:~J.)
NAME (PRINT)