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COUNTY
, i
lCm:VfTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
Dutchess
Wappinger
1368
115
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
P. Brosnan
MIDDLE CURRENT SURNAME
I STATE FILE NUMBER I
(THIS SPACE FOR STATE USE ONLY)
~ )1~1 CO
Lo SUPPLEMENTAL FILE ~
FROM THE BRIDE
Stephanie G.
FIRST MIDDLE
Stewart
CURRENT SURNAME
1. A, FULL NAME
Kevin
FIRST
11. A, FULL NAME
8. BIRTH NAME. IF DIFFERENT
e, BIRTH NAME ,MAIDEN NAME), IF DIFFERENT
C. SURNAME.\!'TER MARRIAGE Brosnan
(OPTIONAL. SEE REVERSE)
D, SDCIALSECURITYNUMBER 082-60-4930
12. RESIDENCE"- New York B Dutchess
ISTATE) ICOUNTY!
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~C1FY Wappinger
D STREET ADDRESS 2gF Alpine Drive zIP12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? - YES ~ NO
13.A. AGE 23 13.B.DATEOFBIRTH Feb. /01 /1977
MONTH DAY yEAR
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
0, SOCIAL SECURITY NUMBER
2, RESIDENCE A, New York
IS"-TEI
c CITY ~ TOWN 0
Wappinger
29F Alpine Drive
C. CHECK ONE
AND
SPECIFY
130-64-4149
B Dutchess
(COUNTY)
VILLAGE
ZIP 12590
D. STREET ADDRESS
YES ~ NO
/1970
YEAR
14. EMPLOYMENT
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3 A. AGE ?Q 3B. DATE OF BIRTH Oct. / 15
MONTH DAY
4, EMPLOYMENT
A. USUAL OCCUPATION Medical Biller
ksB. TYPE OF iNDUSTRY OR BUSINESS HV Hem. IOnc . As so C .
15. PLACE OF BIRTH Kingston, New York
(CITY. STATE/COUNTRY IF NOT USA)
w
!;c
.....
'"
A. USUAL OCCUPATION HV AC Techniciar..
B. TYPE OF INDUSTRY OR BUSINESS Dutchess Co. Public Wo
5. PLACE OF BIRTH (CIJm~~~~lfPvi~~/") New York
6. FATHER
A. NAME
A. NAME David R. Stewart
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Pamela K. Wyant
B. COUNTRY OF BIRTH USA
16. FATHER
Donald J. Brosnan
USA
B. COUNTRY OF BIRTH
7, MOTHER
A. MAIDEN NAME Lillian M. Bullos
B. COUNTRY OF BIRTH USA
lB. NUMBER OF "'HIS MARRIAGE
First
B. NUMBER OF THIS MARRIAGE
First
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
19. PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVCRCE CIVIL ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END? 13\ C DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE 13) C ANNULMENT 2' = DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY "ORMER SPOUSE(S) ALIVE? := YES C NO
20. IF PREVIOUSi..Y DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF JECREE 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? := YES = 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
W
U)
Z
W
(,)
:::::i
1ST - L. 1ST
2ND 2ND
3RD 3RD
4TH ~ 4TH
I, being duly sworn. depose and say, that to the best of my knowledge and belief that the information i provided is true and that I declare that no legal impediment exists
as to my right to enter into the ~a~ri e itate. fi) to (\
21. SIGNATURE OF GROOM ~ '" ~ j/. .6_~ .~~ 22. SIGNATURE OF BRIDE ~ ~ ~ C'\ i"'("\. \. 'l ~ .~ rr \5 1:N
, USEe RENTNAME ~ ~CURRENT"nAr.1IE ~~
23, SUBSCRIBED AND SWORN TO BEFORE ME ........Q.eputy Town Clerk 1 21 2000
SIGNATURE OF TOWN OR CITY CLERK ~ DATE Tl1_ Y - - , ---
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
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 Dr subsequent ceremony.
~ 24 TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} N"''''ffi""Q Elaine H. Snowden, Town Clerk
{SEAL SIGNATURE ~~~ \\. ~l d'^-.t&,,_ DATE 7 /21/00 TIME MONTH DAY YEAR MONTH DAY YEAR
M.wtlGtDDRE~4 W i F 11 NY 12590 AM 07 22 00 09 19 00
~ ~u ox j~, app ngers a s, 2:05 PM
I , A
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
1M AY Y 0 0 RELIGIOUS 1 ~
9 0 OTHER. SPECIFY
25. e. SOLEMNIZATlON PERIOD
ENDS AT MIDNIGHT ON
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED,
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ;2&<5
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECI )
29. OFFICIANT
NAME (PRINT)
VILLAGE OF
NAME (PRINT)
SIGNATURE ~
NAME (PRINT)
S1GNAruRE~
r'V"U.I ftA 111D111l\