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004
23. SUBSCRIBED AND SWORN TO/AFF ED
SIGNATURE OF TOWN OR CITY C RK ~
This license authorizes the marriage In New York State of the bride and groom named above by any person authorized
RelatiDns 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
} "'"','"on '~~
{ SEAL SIGNATURE~ _ r' DATE n1/?R/201
MAILING ADDRESS
'-v-I ~ Middleollsh Rd W~r.nin&WrR Fallsh NY 12590
STR 'CITYIT N TATE ZIP
~~~R~~RTr~J 6~O~~N~~E~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TI M . Y YEAR 0 fil"RELlGIOUS
DATE AND AT THE TIME AND 3 AM
PLACE INDICATED. ~ fJtl 9 0 OTHER, SPECIFY
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST~namdi P~![~ck Opar~~SU~~AME
COUNTYDlItchess
CITYITOWN\^/april"loer
~~J:~c~1368 .
~5~~J~R 4
1. A. FUll NAME
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f:I
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIALSECURITYNUMBER 453-91-~??1
2. RESIDENCE A N'(STATE) B. D(bUSS
C. CHECK ONE 0 CITY.,LJ TOWN 0 VILLAGE
AND \^' .
SPECIFY . appmger
D. STREET ADDRESS 1 SlIrr~y I ::m~: Apt C ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YE9I'tJ NO
M~ / ~AQ /~~6
3. A. AGE23
4. EMPLOYMENT
A. USUAL OCCUPATION Financial .L\ nalyst
B. TYPE OF INDUSTRY OR BUSINESS T echnnlnoy
5. PLACE OF BIRTH ~/!lVj~l~o\JJJvC'F NOT USA)
6. FATHER
3B. DATE OF BiRTH
A. NAME Nnamdi Patrick Oparanozie, Sr
B. COUNTRY OF BIRTH Nigeria
7. MOTHER
A. MAIDEN NAME Teri Lynn lohnsnn
B. COUNTRY OF BIRTH I I S L\
8. NUMBER OF THIS MARF,lIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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o
o
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
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (CITYICOUNTY. STATElCOUNTRY. IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.ose and say, tha
as to my right to enter into the marr g
21. SIGNATURE OF GROOM ~
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en
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w
(..)
::;
29. OFFICIANT
NAME (PRINT)
SIGNATURE ~
MAILING ADDR
f()72
STREET
30. WITNESS TO CEREMONY
NAME(PRINT) ~ ~
SIGNATURE~ -A.
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L
11. A. FUll NAME
o SUPPLEMENTAL FILE
FROM THE BRIDE
Amanda Bianca Enriauez Perez
FIRST MIDDLE CURRENT SURNAME
-.J
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGEOparanozie
(OPTIONAL. SEE REVERSE}; 56-47 7233
D. SOCIAL SECURITY NUMBER 4 -
12. RESIDENCE ~Y BPutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY..o TOWN 0 VILLAGE
AND W .
SPECIFY appmger
D. STREETADDRESS1 Surrey Lane; Apt C
ZIP 12590
o YES~ NO
;t979
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE30 3B. DATE OF BIRTH 03 22
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATIONReception
B. TYPE OF INDUSTRY OR BUSINESS Insurance
15. PLACE OF BIRTHGalveston. TX
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMEEernando Chavez Perez
'B. COUNTRY OF BIRTM S A
17. MOTHER
A. MAIDEN NAME Sylvia Renee Enriauez
B. COUNTRY OF BIRTM S A
18. NUMBER OF THIS MARRIAGE 1
19. ~~~~~dl~R"g'FR~~~<tT8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
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) (CITYICOUNTY. STATElCOUNTRY. IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATli
/ /
.-- YEAR
1ST
2ND
3RD
4TH
that the information I provided Is tr
o
o
o
TIME
MONTH
YEAR
MONTH
YEAR
, AM
12:41PM
01
27
2010
03
27 2010
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY B15r h$HI{Il-1-
/ Z{)3,
ZIP
". WITH'SS =%""'
NAME (PRINT) U\~:\- '{Y\ 1::l'=:lV"e....
SIGNATIJRI=. (1 lA.t\ .L.l..ifY\ C'\.ct\ C\