156
:]
0
en
l.D
N
or-
.:E
I-
~
~ ~
~
Q) '1l
Z
!!!
m
..u.. ...
~0 :>
UJL...
UJQ) <(
~O) C
~w u:::
on. :?
~o.. ~ LL.
~ > <(
z
~ !:
0
0: t"
f- - ~
:QQ) (3
l']-,.
w:-
0:1-
~
~c
~o
;%(1)
:0
0:J
~
<<:
~)
i=('''
0:
UJ
U
UJ
0:
UJ ffi
I
~ "
rn :;
~ ::J
Z
0: 0
0 z
0 <<
<<: f-
>- W
W
"- go
0
UJ U)
"-
rn
LU
(/J
Z
LU
()
::i
~~Q UJ
~~~ ...
~_ ffi z <t
<gd~ ()
~\?~ u:
z-
~~b t=
[Eorn a:
Of- >- LU
w~C3 ()
b~Ul
Z:::i~
COUNT-Rutchess
CITY/TOw~appinger
~~~~kCR' 368
~~~I~J~~ 56
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert M. Sheehan
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
:tll
I-~-C~
~
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Jamie M. Brubacher
A FULL NAME
11. A. FULL NAME
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
0-
N
B BIRTH NAME. IF DIFFERENT
B BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Sheehan
(OPTIONAL - SEE REVERSE{)87-72-2155
o SOCIAL SECURITY NUMBER
12. RESIDENCE ANew York BDutchess
(STATE)"" (COUNTY)
C CHECK Qt;ii; D CITY 0 TOWN 0 VILLAGE
~~~CIFy\Napplnger
o STREET ADDRESf3 Hudson unve
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERS~ 00-72 5662
o SOCIAL SECURITY NUMBER -
2 RESIDENCE ANew York B. Dutchess
C CHECK ONE (STA~) CITY"''b TOWN 0 VILLAGE (COUNTY)
~~~CIFY Fishkill
D. STREET ADDRES~09 Mc Grath Boulevard ZIP 12524
IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VilLAGE' 0 YEs"'b NO
Al3 /1982
DAY
3 A. AGE19
09
DAY
3B. DATE OF BIRTH
MONTH
MONTH
YEAR
4 EMPLOYMENT
A. USUAL OCCUPATION Jet Mechanic
B TYPE OF INDUSTRY OR BUSINES~ir Force
5 PLACE OF BIRTJ3eacon. New York
(CITY, STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATIONSupervisor
B. TYPE OF INDUSTRY OR BUSINESSSam's Club
15. PLACE OF BIRTHYonkers, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMERaymond Brubacher Sr.
B COUNTRY OF BIRTM S A
17. MOTHER
A. MAIDEN NAME Lynne GoldinQ
B COUNTRY OF BIRTM S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DllTH
6. FATHER
A. NAME Patrick Sheehan
B. COUNTRY OF BIRTHU S A
7. MOTHER
A. MAIDEN NAME Sandra Lake
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
DEATH
o
B HOW DID LAST MARRIAGE END' (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B HOW DID 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
MONTH DAY 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 1ST
o 2ND
o 3RD
o 4TH
elief that the information I provided is
o
o
o
o
o
o
22. SIGNATURE OF BRIDE
21
23 SUBSCRIBED AND SWORN T FORE ME
SIGNATURE OF TOWN OR CI CLERK ~ DATE
This license authorizes the marriage in New York authorized by New York Domestic
Relations Law 911 to perform marriage ceremonies wit I New York Slate. 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. Morse
{SEAL SIGNATURE ~ ----0/2-) t<. . -'7 ~.I ~I neJ:F 12/26/2001 TIME MONTH YEAR MONTH
'-y-I ~T~~MfJar~bush Rd, \(11PPi~~w~alls, N~TA~2590 01 :37 ~~ 12 27 2001 02 24 2002
27. TYPE OF CEREMONY
YEAR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
ZIP
l~IL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNT~"'-~~
RELIGIOUS
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /'
o CITY OF 0 TOWN OF ~LLAGE~ jJ.
tJECIFY W~~('\b ~
NAME (PRINT)
SIGNATURE ~
NAME (PRINT)
SIGNATURE ~