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COUNTY
CIX7/TOWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Donovan N.
FIRST MIDDLE
I
~
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
Dutchess
Wappinger
1368
169
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Patricia A. O'Neil
--1
1. A. FULL NAME
Leonard
CURRENT SURNAME
MIDDLE
11. A. FULL NAME
CURRENT SURNAME
FIRST
Q.
N
B BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE 0 ' N e i I
(OPTIONAL' SEE REVERSeo 18-6 2-6639
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNlY)
C. CHECK ONE 0 CITY ~ TOWN C VILLAGE
~~CIFY Fishkill
D. STREET ADDRESS ~1 Town View Dr.
a p!:ngerl:l YaIII:l
E, IS RESIDENCE WITHIN L1MI S OF CITY OR INCORPORATED VILLAGE?
13, A, AGE 30 13.B. DATE OF BIRTH Aug. /06-
MONTH DAY
YES ~ M;
/1970
YEAR
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 145 78 7 120
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. North Carolina
(STATE,
~ CITY 0 TOWN 0
Raleigh
D STREET ADDRESS 3537 -202
C. CHECK ONE
AND
SPECIFY
B. Wake
ICOUNlYl
VILLAGE
ZIP 12590
Ivy Commons ZIP 27606
tH.
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? :lb
3. A. AGE 25 3B. DATE OF BIRTH April / 19
MONTH DAY
YES 0 NO
/1975
YEAR
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Engineer
B. TYPE OF INDUSTRY OR BUSINESS IBM
15, PLACE OF BIRTH Holyoke, Mc.ssachusr~tts
(CllY, STATE/COUNTRY IF NOT USA)
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...
(/)
A. USUAL OCCUPATION S tuden t
B TYPEOFINDUSTRYORBUSINESS NC State University
5. PLACE OF BIRTH Red Bank, New Jersey
ICIlY, STATE/COUNTRY IF NOT USA)
16. FATHER
6. FATHER
A. NAME Thomas J. 0 'Neil
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Jean E. Burke
B COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE Firs t
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A. NAME Donald J. Leonard
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Barbara M. Ruccio
B. COUNTRY OF BIRTH USA
B. NUMBEROFTHISMARRIAGE First
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE !OND? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. WJW DID LAST MARRIAGE END? (310 DIVORCE (31 =:J ANNULMENT 2' = :E....-:"
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY v~-'R
D ARE ANY FORMER SPOUSE(S) ALIVE? = YES ;:: NO
20. iF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING NFCRMA7'CN
DATE OF DECREE PLACE ISSUED AGAINST WHOM
,MONTH. DAY. YEAR) (CITY. STATE/COUNTRY. IF NOT USA) SEc.: SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? :::I YES ::J NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) ICITY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 C
2ND 0
3RD 0
4TH
1515
21.
23.
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This license authorizes the marriage in New York State of the bride and groom named a ove by a y person authorized
Relations Law ~11 to perform marriage ceremonies within New York State, THIS LICENSE VALID IN NEW YORK STATE ONLY.
~ 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 IPRI~aine H. ~wden, Town Clerk
{SEAL SIGNATURE~O(lH\,~'Q;A.ir,,^rAt~ DATE9/12/00 TIME MONTH DAY YEAR
MAILING ADD~ 11 4(j\M 09 13 00
~ P.O. Box 324 Waopingers Falls NY 12590 : PM
STREET CllYrrOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27, TYPE OF CEREMONY
THE MARRIAGE OF THE PER. ;V
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0.)8 RELIGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED ~ 01) PM / t1 9 0 OTHER. SPECIFY
by New Yorl<. Domestic
25. B. SOLEMNIZATION PERICO
ENDS AT "'IONIGHT ON:
MONTH
DAY
YEAR
11
11
00
1 = CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~ -f iff ,:;,.,.,
29. OFFICIANT
NAME (PRINT)
1i.1111-' r fir (;(
C, LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF [] TOWN OF I2"VILLAGE OF
SPECIFY C:'L,ld S.''7ri~
NAME (PRINT)
SIGNATURE ~