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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Christopher P.
FIRST MIDDLE
Dutchess
Wappinger
1368
153
Short
1. A FULL NAME
CURRENT SURNAME
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER
2. RESIDENCE A. New Yo r k
(STATE)
o CITY riC TOWN :J
Wappinger
o STREET ADDRESS 17D Scarborough Lane
C CHECK ONE
AND
SPECIFY
103-50-4970
B. Dutchess
(COUNTY)
VilLAGE
ZIP
12590
E. is RESIDENCE WITHIN LIMITS OF CITY OR iNCORPORATED VILLAGE? 0 YES ~ NO
3 A AGE 28 3B. DATE OF BIRTH Aug. / 19 /1972
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Manufac turing Operator
B. TYPE OF INDUSTRY OR BUSINESS Phillips Semiconduc
5. PLACE OF BIRTH :poughkeepsie, New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Thomas P. Short
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Patricia Hand
USA
First
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END? (31 c:: DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? :J 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
o
o
o
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEFORE ME J
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St e of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New 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.
,-I'-. 24 TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) ~aine H. Anowden. Town Clerk TIME MONTH DAY YEAR
SEAL SIGNATURE ~E::::Qa I LV U ~~"" DATE 9 / 1 /00
MAILING ADDRE~ AM
~ PO Box ]24 Wa in ers Falls NY 12590 1:45 PM
STREET ITYITOWN S AT ZIP
~~R~~RT~~~ IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR oli(RELlGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED 2:. 3 0;; 0 0 9 0 OTHER, SPECIFY
w
en
z
w
o
::;
29. OFFICIANT
NAME (PRINT)
I
STATE RLE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Allison Marie
FIRST MIDDLE
-.J
11. A. FULL NAME
Brady
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 130 -56 -3 9 19
D SOCIAL SECURITY NUMBER
12. RESiDENCE A. New York B Du tchess
(STATE) , ICOUNTY)
o CITY ~ TOWN 0 VilLAGE
Wappinger
D. STREET ADDRESS 17D Scarborough Lane ZIP
Short
C. CHECK ONE
ANO
SPECIFY
12590
., YES X: NO
/1975
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 24 13.B. DATE OF BIRTH Nov. /19
MONTH DAY
14. El,IPlOYMENT
A USUAL OCCUPATION Dental Office Administration
or%. TYPE OF INDUSTRY OR BUSINESl? Leonard, Kobren, DDS
15. PLACE OF BIRTH Bronx, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
John J. Brady
USA
Reed
Mary Ellen
USA
First
lB. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
B. U(JW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
31 c::: ANNUWENT
/ /
\21 c::: DEUH
MONTH DAY YEAR
o ARE ANY FORMER SPOUSE(S) ALIVE? eYES c::: NO
20. iF ?REVIOUSl Y DIVORCED OR ANNUlED. PROVIDE THE FOLLOWING iNFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
MONTH. DAY. YEAR) (CITY, STATE/COUNTRY, IF NOT USAI SELF SPOUSE
22. ~'GNATURE OF BRIDE ~
Deputy Town
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
9
2
00
10
31
00
1 = CIVil
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEWYORK B. COUNTYO\.(t-c~S>
TITLE RfJ./ - R.C - P Vl' p 5+
DATE I tJ - 7 - D 0
{V-y.
STATE
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VilLAGE OF
SPECIFY ~ "l,k- -;;i l h r:-d t
IOO7.:r
ZIP
31. WITNESS TO~NY
I
NAME (PRINT) '", 0
SIGNATURE ~