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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert Victor
FIRST MIDDLE
Dutchess
Wappinger
1368
188
Reardon, Jr.
CURRENT SURNAME
11. A. FULL NAME
I STATE FILE NUMBER "I
(THIS SPACE FOR STATE USE ONLY)
~ \}l.loll
\'0
Lo SUPPLEMENTAL FILE .J
FROM THE BRIDE
Dawn Marie
FIRST MIDDLE
O'Mara
CURRENT SURNAME
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B. Orange
,STATE) (COUNTY)
X CITY :: TOWN 0 VILLAGE
Middletown
o STREET ADDRESS 12 Spruce Peak Road
B. BIRTH NAME ,MAIDEN NAME), IF DIFFERENT
" SURNAME .~FTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York
ISTATE)
o CITY Xi TOWN C
Wappinger
D. STREET ADDRESS 15D Canterbury Lane
B BIRTH NAME. IF DIFFERENT
058-70-2545
C. CHECK Cl'lE
AND
SPECIFY
C. CHECK ONE
AND
SPECIFY
ZIP 10940
E. IS RESIDE."<CE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? - YES X: NO
13. A. AGE 31 13.8. OATE OF BIRTH Aug. /24 /1969
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? i>> YES 0 NO
Sept. /25 /1969
MONTH DAY YEAR
3. A. AGE
31
3B. DATE OF BIRTH
14. EMPLOYMENT
4. EMPLOYMENT
REARDON
051-62-9799
DutchesH
.COUNTY)
VILLAGE
B.
ZIP
12590
Account Clerk
A. USUAL OCCUPATION Glazier
B. TYPE OF INDUSTRY OR BUSINESS Self-employed
5. PLACE OF BIRTH parkchester. New York
(CITY. STATl;COUNTRY IF NOT USA)
A. USUAL OCCUPATION
B. TYPE OF INDUSTRY OR BUSINESsDutchess Community
15. PLACE OF BIRTH Bronx. New York
(CITY, STATE/COUNTRY IF NOT USA)
Colleg
6. FATHER
16. FATHER
A. NAME
A. NAME Robert Victor Reardon. Sr.
B. COUNTRY OF BIRTH USA
7. MOTHER
Thomas W. O'Mara
USA
B. COUNTRY OF BIRTH
A. MAIDEN NAME
Grace Day
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
USA
First
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE
Roseann Bretone
First
18. :-.lUMBER OF THIS MARRIAGE
1S. pqEVIOUS MARRIAGES
A. NUMBEq OF PREVIOUS MARRIAGES WHICH ENDE:J BY
DIVCRCE CIVIL ANNULMENT
DEATH
8. HOW DID wIS, MARRIAGE END? (3) 0 DIVORCE ,3) = ANNULME!'<T 2) = CE.~~"
v. DATE LAST MARRIAGE ENDED? / /
MONTH )AY YEAR
:J. ARE ANY FORMER SPOUSE(S) ALIVE? = YES = NO
20. F PREVIOUSLY DIVORCED OR ANNULED. PROVIDE TI-'E "OLLOWING INFORMATICN
DATE OF DECREE PLACE ISSUED AGAINST WHCM
,MONTH. JAY. YEAR) (CITY. STATElCOUNTRY. IF NOT JSAI SELF SPOUSE
o C 1ST
:J c- 2ND
[J 3RD
C C 4TH
est of my knowledge and belief that the ,nformatlon I provided I~d that I declare that no legal Impediment eXists
22. SIGNATURE OF BRIDE ~ ~f). .... "--~ )J..... (\ "\-'c 'l. \,....~
. USE CURRENT ~ "'''- -
23 Deputy Town Clerk JATESept. 28, 2000
This license authorizes the marriage in New York te of the bride and groom named above by any person authorized by New York Domestic
Relations Law 911 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
:J If checked, this license is to be used only lor the purpose 01 a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
Elaine H. Town Clerk
DATE 9/28/00
NY 12590
STATE
27. TYJE OF CEREMONY
o a;( RELIGIOUS 1 = CIVIL
9 0 OTHER. SPECIFY
S. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END? <3) = 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 sa
as to my right to enter into
21. SIGNATURE OF GROOM
w
en
z
w
o
:i
~
{ SEAL}
~
NAME (PRIN
STREET
I CERTIFY THAT I SOLEMNIZEO
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON,
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
ZIP
11 :45AM
PM
9
29
00
11
27
00
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY It. +:.!.L ","
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
-- f r. h
SPECIFY /:;:.iA:5' ,vI$, f.i/ I
29. OFFICIANT
NAME (PRINT)
TITLE
~b)hl6IAtl1~ Ir/I!.:f
/0/1-1/00
. I /
ATE
STATE ZIP
NAME (PRINT) NAME (PRINT)
SIGNATURE ~,
DOH-SB (1198)
SIGNATURE ~