Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
053
+
w
~
~
N
U")
N
T""" ...
~>- :>
wZ c(
~ e
5=~L&.
~~~L&.
~~~c(
0'-3
~u..g
1Il"'O~
ffio::'"'
~ ....
~
if
~
...
o
~
'"'
ii:
~
w
'"'
w
a:
w
~
III
III
w
a:
o
o
<0(
~
o
w
"-
III
w
en
z
-w
o
::i
+
~~z
~~~ W
a:"~ ~
l;;~~ 0
::>ow
~<.!l5 u::
tz~1Il -
~~t5 t:
[EO(/) W
~~~ 0
~ffi~
~3~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael Aaron McKeehan
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~:1368
~~~I:J~R 53
1. A. FULL NAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE>1 00-76-0357
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(ST ATE) (COUNTY)
C. CHECK ONE 0 CITYo{] TOWN 0 VILLAGE
~~~CIFY Fishkill
o STREET ADDRESS 111 Cooper Rd ZIP 12524
E. IS RESIDENCE WllHlN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ""'0 NO
3. A. AGE 25 3B. DATE OF BIRTH 10 / 17 /1984
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Programmer
B. TYPE OF INDUSTRY OR BUSINESS Utility
5. PLACE OF BIRTH Beacon, NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Michael Milton McKeehan
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Carol Ann Lehning
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,\IAGE 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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
a:'
w
"'
~
::>
z
o
z
<0(
tii
w
~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
Orl~11
NAME (PRINl) iJ t KtJh/ --
r>1,.."IATllnr...... r.l'1 fV'j". ~
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Michelle Fornabaio
~
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGEMcKeehan
(OPTIONAL - SEE REVERSE~ 1 0-76-7619
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY Boutchess
(STATE).L.. (COUNTY)
C. CHECK QI'iE. 0 CITY -U TOWN 0 VILLAGE
~~~CIFYvvappmger
hU I op U Hili KO '12590
D. STREET ADDRESS- ZIP "'"
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES f8 NO
13. A. AGE22 3B. DATE OF BIRTH 11 Y1 .l9 7
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATIONManager
B. TYPE OF INDV~TRY OR BUSI~~~Ketall
15. PLACEOFBIRTHyonl<ers, NY
(CITY, STATE / COUNTRY IF NOT USA)
16, FATHER
A. NAMEJoseph Anthony Fornabaio
'B. COUNTRY OF BIRTJ-J S A
17. MOTHER C h' AT"
A. MAIDEN NAME ynt la nn aCjl
B. COUNTRY OF B;:-J-J S A
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DffORCE CIVIL A~ULMENT
DtfTH
(3) 0 ANNULMENT (2) 0 DEAlH
/ /
..- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
~
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY,IF NOT USA) SELF SPOUSE
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED ') ~
A. STATE NEW YORK B. COU~~'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITYOF~N~ WL
SPECIFY P~'Vfi!.A-
ZIP
31, WITNESS TO CEREMONY
:~~~~:::~~~ ~~h~"b