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COUNTY Dutchess
CITYrrOWN WappinQer
~~J~f; 1368 '
~5~I:J~R 137
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Alberto Joel Mendez Perez
MIDDLE CURRENT SURNAME
r
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
1. A. FULL NAME
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME Maria Natividad Castrejon Dominguez
FIRST MIDDLE CURRENT SURNAME
~
FIRST
II.
I'l
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSI;l_____
D. SOCIAL SECURITY NUMBER xxx - xx - xxxx
2. RESIDENCE A NY B. Dutchess
(STATE) (COUNT'f)
C. CHECK ONE 0 CITY..o TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 792 Old Route 9 ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES~ NO
3. A. AGE 2R 3B. DATE OF BiRTH 04 /09 /1981
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE099_90_6133
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(STATE) ..L (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN~ VILLAGE
~~~CIFYWaP..Ein~ers Falls
D. STREET ADDRESJ38 Prospect St ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? ....0 YES 0 NO
.24 )979
DAY YEAR
08
13. A. AGE30
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Cook
B. TYPE OF INDUSTRY OR BUSINESS Chubby's Deli
5. PLACE OF BIRTH Oaxaca. Mexico
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Joel Mendez Silva
B. COUNTRY OF BIRTH Mexico
7. MOTHER
A. MAIDEN NAME Elvia Perez Faiardo
B. COUNTRY OF BIRTH Mexico
8. NUMBER OF THIS MARF,IIAGE 1
9. ~~~~~~~R~FR~~1:~8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATIONCleaning
B. TYPE OF INDUSTRY OR BUSINESS Maintenance
15. PLACE OF BIRT~totonilco, Mexico
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEJ. Natividad Castrejon Quevedo
'B. COUNTRY OF BIRT~exi co
17. MOTHER
A. MAIDEN NAME Florentina Dominguez Morellano
B. COUNTRY OF BIRT~exico
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
(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. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
MONTH 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
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swellr/afflrm, dep.ose and say, tha to thr best of my k~ led e and belief that the Information I provided is true and that I declare thal no legal impediment exists
as to my nghtto enter Into the mam tate ' J'
21. SIGNATURE OF GROOM~ ~.O . 1'\ 22. SIGNATURE OF BRIDE~ .-.H.-..~
USE R NT NAME ~RENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME 12/03/2009
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
W Relations Law ~11to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
en 0 If checked, this license is to be used only for the urpose of a second or subsequent ceremon .
Z ~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
W } NAME (PRINT) Joh C. Masterson
(.) { . TIME MONTH YEAR MONTH
::i SEAL SIGNATURE ~, DATE 12/03/2009
'-v-I MAI2(nHldd~~ sh Rd. WappinQers Falls, NY 12590 09:56AM 12 04 2009 02 01 2010
STREET ClTYtrOWN STATE ZIP PM
~~:R~~RT~~J 'o~O~~N~~~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME DAY YEAR 0 0 RELIGIOUS 1 ~ CIVIL
DATE AND AT THE TIME AND W -AM
PLACE INDICATED. _ PM 9 0 OTHER, SPECIFY
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~J~.ff~s..5;'
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY O~. ?/TOWN O~VILLA,GE p;.
SPECIFYp(I~~/~j ~
29. OFFICIANT
NAME (PRINT)
(~~S1~
. "nE ftc, 12, ~
'/;f:J,tOi;Jeeeg . ILI!I / t?
STATE ZIP
31. WITNESS TO C~ONY
Ik /J1E:fIJbb.:.- NAME (PRINT) Il ~.~;f;;J!i~ z...
SIGNATURE~ R
NAME (PRINT)
SIGNATURE~