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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thomas Richard O'Connor
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV'1RCE CIVIL AN~LMENT
~
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCO (3) 0 AN4LMENT 2(Ba~EATH
C. DATE LAST MARRIAGE ENDED? 8 / 1 /
MONTfV DAY
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
(~OJ:lTIj, D....Y2):.EAf3l. (CITYICpU,NTY, STATElCOU"l.T~Y. IF NQ~ US,,\l SELF SPO~E
1ST ut:S1141 UUL PougnKeepsle, New YOrK 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose and say, that to thA::b st of my know e and belief that the information I provided is true and that I declare that
as to my right to enter into the m te.
21. SIGNATURE OF GROOM ~ .
USE CUR
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
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 or subsequent ceremony.
~ 24. TOWN OR CIIJ8'tf~KC. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)
SEAL SIGNATURE ~ . (. DATE 09/14/201 TIME MONTH YEAR MONTH
'-v-I MAI~Mfa~b h Rd, Wappingers Falls, NY 12590 03:41~~ 09 15 2010 11
STREET CITYfTOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
COUNTY Dutchess
CITYfTOW)j Wappinger
DISTRICT 1368 .
NUMBER
REGISTER 127
NUMBER
1. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
c.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 050-62-4644
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY B. Dutchess
(STATE).L (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~CIFY Wappinger
D. STREET ADDRESS 23 Montfort Rd ZIP 1 Lb~U
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
02 / 28 / 1962
DAY YEAR
3. A. AGE 48
3B. DATE OF BIRTH
MONTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Retired Police
B. TYPE OF INDUSTRY OR BUSINESS Law Enforcement
5. PLACE OF BIRTH Yonkers, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Patrick Jose~ Q'Connor Sr.
B. COUNTRY OF BIRTH U S
7. MOTHER
A. MAIDEN NAME Maureen Ann Q'Donoghue
B. COUNTRY OF BIRTH Ireland
8. NUMBER OF THIS MARRIAGE 2
DEtJH
YEAR
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STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Shiela Balili Dumukmat
-.l
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SEC;;U.RITY NUMBER xxx - xx - XXXX
12. RESIDENCE A. NY B. LJutchess
(STATE)..t (COUNTY)
C. CHECK O~1i. . 0 CITY 0 TOWN 0 VILLAGE
~~CIFY vvapplnger
2~ Montfort Rd
D. STREET ADDRESS
12590
ZIP
.,
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORAT~ VILiAGE? 0 YES 97~O
AGE 34 13BDATE OF BIRTH 8 ~ 1 )t
MONTH DAY YEAR
13. A.
14. EMPLOYMENT
A. USUAL OCCUPATION Nurse
B. TYPE OF INDU$JRY OR BUSINESS Healtncare
15. PLACE OF BIRTH I\ICapaWan, ~hlllpplneS
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Francisco G. Dumukmat
. B. COUNTRY OF BIRTH ~hlllpplnes
17. MOTHER T M B IT
A. MAIDEN NAME eodora . a I I
B. COUNTRY OF BIRTH ~hlll~Plnes
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1'tfRCE CIVIL AN~ULMENT
DE6TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
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 D
o 0
o D
o D
o legal impediment exists
29. OFFICIANT
NAME (PRINT)
USE CURR T NAME 09/14/2010
DATE
YEAR
1 j2! CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY/A) 11:.{fE-q::;
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF AVILLAGE OF
SPECIFY f(/fh1f1t/C~ filas.
SIGNATURE~