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127 + .... z w '" w '" o ..J :;) o J: '" Z o ~. .... '" a w 0:: W Cl < i:[ 0:: < ::E u.. o w ~ C,,) ii: ~ w C,,) w 0:: w J: ~ '" '" w 0:: o o < t u w a. '" w en z w 0 ::i + ~~5 W tu~"" ~ 0::><;5 < ~~~ 0 :;)C,,)W ::EClcS LL ....z'" j: z- ~~~ a:: fE~~ w o < 0 w~c I-ffill') gg~ 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 .... :> <C c wLL "'LI. ~< 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 a: w III ::E :J Z o z < Iii w a:: Iii I 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~