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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jonathan Fabrizio Teran
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYiTOWN Wappinger
~~~:~c;: 1368 .
~5~:J~R 133
1. A. FULL NAME
FIRST
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY
(STATE)
C. CHECK ONE 0 CITY o(j
~~CIFY Wappinger
D. STREET ADDRESS 316 Chelsea Cay ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"tJ NO
09 /18 /1987
MONTH DAY YEAR
B. Dutchess
(COUNTY)
TOWN 0 VilLAGE
3. A. AGE 22
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Construction Company
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH Guyaauil. Ecuador
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Fabian Fabrizio Teran
B. COUNTRY OF BIRTH Ecuador
7. MOTHER
A. MAIDEN NAME Katty Mirvam Contreras
B. COUNTRY OF BIRTH Ecuador
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
YEAR
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
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Hannia Rebeca Alfaro
MIDDLE CURRENT SURNAME
.-J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE T era n
(OPTIONAL - SEE REVERSE113_76_1596
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VilLAGE
~~~CIFY Wa~inger
D. STREET ADORE 16 Chelsea Cay
ZIP 12590
DYES tJ NO
..%988
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE21 3B. DATE OF BIRTH 07 A8
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Dental Assistant
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH Southampton, New York
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMEGerman Eduardo Alfaro
'B. COUNTRY OF BIRTHCosta Rica
17. MOTHER
A. MAIDEN NAME Hannia Judith Portilla
B. COUNTRY OF BIRTHCosta Rica
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. ',- YEAR
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
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1ST
2ND
3RD
4TH
I duly swear/affinn, dep.ose and say, th
as to my right to enter into the marn
21. SIGNATURE OF GROOM~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
dge and belief that the infonnation 'I provided is t~
o 0
o 0
o 0
o 0
impediment exists
23. SUBSCRIBED ANU SWORN T
SIGNATURE OF TOWN OR
This license authorizes arriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perfonn 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 urpose of a second or subsequent ceremony.
24, TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
SIGNATURE~
DOH-98 (0312006)
w
en
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~ { } NAME (PRINT) . ,
::i SEAL SIGNATURE ~ DATE 11/23/2009
'-v-' MAI~cr~r S ush Rd iners Falls NY 12590
STREET CITYITOWN STATE ZIP
~~~R~~RTr~J IO~O~~N~~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME M . AY YEAR 0 IliiI RELIGIOUS
DATE AND AT THE TIME AND AM 21
PLACE INDICATED. i" M II oct 9 0 OTHER, SPECIFY
~~.Jt~~9!~ BroC-e {(. eeedlJ TITLE Pr6;lcL~ MinIster
SIGNATURE~~ 11. O~JI DATE II {Z7/01
MAiliNG ADDRESS '1 Y
tll ~~dr.ll~ l2.\dqa Dr Hooou.dl Id tJ
STREET CITYfTOWN STATE
30. WITNESS TO ~EMONY
NAME (PRINT) ~
DATE
by New York Domestic
TIME
MONTH
MONTH
YEAR
YEAR
AM
01 :41 PM
01
22 2010
24
2009
11
2B. PLACE WHERE MARRIAGE OCCURRED
10 CIVil
Ovfd.1es~
A. STATE NEW YORK B. COUNTY
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF Ilii1 TOWN OF 0 VilLAGE OF
SPECIFY \A)avflY~pr.5
SIGNATURE