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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Frank James LeBlanc
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
DISTRICT 1368 .
NUMBER
REGISTER 128
NUMBER
1 . A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1 04-76-7239
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) J.. (COUNTY)
C. CHECK ONE 0 CITY L..J TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 11 Marlorville Rd. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
3. A. AGE 25 3B. DATE OF BIRTH 08 / 06 / 1985
MONTH DAY YEAR
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4. EMPLOYMENT
A. USUAL OCCUPATION Power Plant Operator
B. TYPE OF INDUSTRY OR BUSINESS Energy
5. PLACE OF BIRTH Yonkers, NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME James Frank LeBlanc
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Carmel Margaret Harkin
B. COUNTRY OF BIRTH En11and
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 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 ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
LynneMarie Gagne
MIDDLE CURRENT SURNAME
-1
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Gagne-LeBlanc
(OPTIONAL - SEE REVERSE) 130-74-1634
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STATE) ~ (COUNTY)
C. CHECK ONE c;l CITY [J TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 11 Marlorvllle Rd. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 25 13B.DATE OF BIRTH 01 fi8 )1'985
MONTH DAY YEAR
14. EMPLOYMENT
A, USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS Mercy College
15. PLACE OF BIRTH Terceira, Portugal
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Daniel Jean Gagne
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Nancy Lynne Vicario
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DE~TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
~
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
1ST
2ND
3RD
o
o
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o
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to the be t of
as to my right to enter into the marnage state
21. SIGNATURE OF GROOM ~
YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TY". OF CEREMONY
o ~RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A, STATE NEW YORK B. COUNTY pwfno W1
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFYr!afrlAl'l (l/lAhnpCtC')
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-98 (0912009)
NAME (PRINT)
SIGNATURE~