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COUNTY
~rTOWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ryan
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
Dutchess
Wappinger
1368
110
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SUPPLEMENTAL FILE
FROM THE BRIDE
Nicole Marie
FIRST MIDDLE
Sclafani
CURRENT SURNAME
1. A. FUll NAME
Mulcahy
CURRENT SURNAME
11. A. FUll NAME
MIDDLE
B. BIRTH NAME. IF DIFFERENT
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER
New York
(STATE)
C. CHECK ONE 0 CITY rX TOWN
AND W.
SPECIFY app~nger
D. STREET ADDRESS 518 Chelsea Cay ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
13.A. AGE 25 13.B.DATEOFBIRTH March /16 /1975
MONTH DAY YEAR
Mulcahy
134-72-9638
Dutchess
(COUNTYI
o VilLAGE
C. SURNAME AFTER MARRIAGE
IOPTIONAL . SEE REVERSE)
o SOCIAL SECURITY NUMBER
2 RESIDENCE A. New York
(STATE)
c CITY ~ TOWN C
Wappinger
o STREET ADDRESS 518 Chelsea Cay
C CHECK ONE
AND
SPECIFY
101-62-6558
Dutchess
(COUNTY)
VilLAGE
12. RESIDENCE A.
B.
B.
ZIP 12590
o YES ~ NO
16 /1973
YEAR
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE?
3. A. AGE 26 3B. DATE OF BIRTH OC t. /
MONTH
DAY
14. EMPLOYMENT
4. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS YMCA We s t c he s t e r
15. PLACE OF BIRTH Carmel, New York
(CITY, STATE/COUNTRY IF NOT USA)
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Whi t e P la ins
5. PLACE OF BIRTH White Plains. New
ICITY, STATE/COUNTRY IF NOT USA)
Schl. Dist
York
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Judith Leissler
USA
First
Jerry Mulcahy
USA
John C. Sclafani
USA
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
3. COUNTRY OF BIRTH
Jean DIAnna
USA
First
18. NUMBER OF THIS MARRIAGE
8. NUMBER OF THIS MARRIAGE .
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DE~TH
B. HOW DID LAST MARRIAGE END? (3) == DIVORCE
C. DATE LAST MARRIAGE ENDED?
31 = ANNULMENT
/ /
2' = DEATH
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) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? eYES = NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. 'JAY. YEAR) (CITY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
o
[J
i'
Town
w
en
z
w
(J
::J
23. SUBSCRIBED AND SWORN TO BEF E M
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.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
laine H. Snowden Town Clerk
DATE 7/13/00
NY 12590
STATE
27. TYPE OF CEREMONY
9
11
00
DATE
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
'-v-I
NAME (PRINT)
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
SIGNATURE ~
MAILING ADDRE
PO Box 3
STREET
I CERTIFY THAT ( SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
AM
3 :00 PM
00
7
14
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY tI.sz.5
1 = CIVIL
OTHER. SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF "z!TOWN OF ::: VILLAGE OF
~,., "<: ~ $
SPECIFY
tJ