027
1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Kevin Thomas
FIRST MIDDLE
I
STATE FILE NUMBER
(THIS SPACE ~OR STATE USE ONLY)
I
COUN'N Dutchess
CITYITOW~appinger
2~~~~; 1368
~5~~J~R 27
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L 0 SUPPLEMENTAL FILE
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FROM THE BRIDE
Jillann
FIRST
Chase
CURRENT SURNAME
McCourt
CURRENT SURNAME
11. A. FULL NAME
MIDDLE
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 052-62 1562
D SOCIAL SECURITY NUMBER -
New York
(STATEI
C. CHECK ONE C CITY []I: TOWN 0 VILLAGE
~~~CIFY pou~hkeepsie
o STREET ADDRESS 64 Mair. St.
. New Hambur2
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 24 3B. DATE OF BIRTH June /
MCNTH
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT -
C. SURNAME AFTER MARRIAGE McCourt
(OPTIONAL. SEE REVERSE) 063-72-8445
D SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN Xl VILLAGE
~~~CIFY Wappingers Falls
o STREET ADDRESS 8 Roy Ave. ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES:::: NO
13.A. AGE 28 13.B.DATEOFBIRTH April /10 /1971
MONTH DAY YEAR
2. RESIDENCE A
B.
Dutchess
(COUNTY)
ZIP 11SQO
']YEsDNO
13 /1975
DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
St. Francis Hospital
4. EMPLOYMENT
A. USUAL OCCUPATION Mechanic
B. TYPE OF INDUSTRY OR BUSINESS W . R . Re p air S e rv ice
5. PLACE OF BIRTH New York .New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH 'P 011 0' 'h In><'' n cd I> t. 1\1 I>TJ
(CITY. STJi'fE/COUNTA'i'1I' NOT uSA)
16. FATHER
A. NAME John Chase
B. COUNTRY OF BIRTH USA
17. MOTHER
vo,.1c
A. NAME John Mc Court
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME
T111; I> 1'111"1"11>
Salaun
Jacqueline
USA
8. NUMBER OFTHIS MARRIAGE First
A. MAIDEN NAME
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE
Fir!'lt.
B. COUNTRY OF BIRTH
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 ANNULlMENT
/ /
(2) C DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) :::: ANNUL.'~ENT
/ /
21 :::: DEAr~
YEAR
YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? :::: YES :::: NO
20. 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
MCNTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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
21.
1ST
2ND
3RD
4TH
I. being duly sworn, depose and say, that h
as to my right to enter into the marriage te
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22. SIGNATURE OF BRIDE ~
DATE Marl'h 24. ?OOO
by New York Domestic
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23. SUBSCRIBED AND SWORN TO
SIGNATURE OF TOWN OR CI CLERK
This license authorizes the marriage in New York State of the bride and groom named above by ny 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 onl for the urpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) ~lai}!.f. Jb.... Snowden. Town Clerk
{SEAL SIGNATURE ~ 1/.iJ ~ ~AI\A'~/^, DATE3/24/00 TIME MONTH DAY YEAR
'- -.J MAILING ADORES. 9: 00 AM 03 25 00
--v-- S E PM
~~~R~:RT:~ 10~0~~~N~Z:~ 26. SOLEMNIZATION OCCURRED
SONS NAMED ABOVE ON THE TIME AY YEA
DATE AND AT THE TIME AND
PLACE INDICATED.
05
23
00
25. B. SOLEMNIZA TlON PERIOO
ENOS AT MIDNIGHT ON:
MONTH
DAY
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
...<~~
27. TYPE OF CEREMONY
o ~ELlGIOUS
9 0 OTHER. SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 9\VlUAGE OF
SPECIFY (. n 9P({'\3pc" ~Q.lIS
1 C CIVIL
A. STATE NEW YORK B. COUNTY Ot..ctc.hesS
00
~~:~~~~ri ~e.u. '.SCL('\n( c B. Maf'liZoTlTLE 1"1 t(\\'S~er
SIGNATURE ~ ...J). ~ 0 .~ '-8. rrr7 Otd Z. "I-I noOO
MAILING AOOR~ ~
Q\'\) ($"
STREE
30. WITNESS TO CEREMONY
NAME (PRI~(V"e ('.J>G. ~
SlGNATURE~Ju~ ("'I..." #
DOHo9lI I1Ill8l
ZIP
31. WITNESS TO CEREMqNY I
NAME (PRINT) 'l ·
SIGNATURE ~
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