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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Anthonv Kevin Marquez
FIRST MID!SLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COUNTY Dutchess
CITYrrOWN Wappinger
~~J~~c~ 1368 .
~5~I:J~R 128
.J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Dina Allen
11. A, FUll NAME
CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERErJ::ader
C. SURNAME AFTER MARRIAGE M a rq uez
(OPTIONAL - SEE REVERSEQ03_52_4602
D. SOCIAL SECURITY NUMBER
12 RESIDENCE ANY . BPutchess
(STATE) .L. (COUNTY)
C. CHECK ONE P CITY Q TgWWU VilLAGE
~~~CIFYWapplngers t-alls
D. STREET ADDRESP Lower Henry ~t
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEl060 64 1946
O. SOCiAl SECURITY NUMBER --
2. RESIDENCE A, NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN"tJ VilLAGE
~~~CIFY Wappin~ers Falls
o. STREET ADDRESS 6 Lower Henry St ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? '6 YES 0 NO
04 /06 /1966
MONTH DAY YEAR
04
YES 0 NO
)972
YEAR
13. A. AGE37
3. A. AGE 43
3B. DATE OF BIRTH
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Supervisor
B. TYPE OF INDUSTRY OR BUSINESS NY City Sanitation
5. PLACE OF BIRTH Manhattan. NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME William Marauez
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary E. Perez
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATIONSocial Worker II
B. TYPE OF INDUSTRY OR BUSINESS Mental Health
15. PLACE OF BIRTHHarvard, Mass
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME William Allen
'B. COUNTRY OF BIRTJ.! S A
17. MOTHER
A. MAIDEN NAME Linda LaMontagne
B. COUNTRY OF BIRTJ.! S A
18. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1V~rCE CIVIL ANOULMENT DEaTH DI1'ORCE CIVIL A'OULMENT D'BTH
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (o~ DEATH
C. DATE LAST MARRIAGE ENDED? 05 / 23 / 2005 C. DATE LAST MARRIAGE ENDED? 01 / 06 / 20 .
MONTH DAY YEAR MONTt\II DAY' ',- YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES ONO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITVICOUNTY, STATEICOUNTRY. IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
OS/23/2005 Queen. Ny ~ 0 1ST 01/06/2005 Poughkeepsie, NY 0 ~
o 0 ~D 0 0
o 0 3RD 0 0
o 0 4TH 0 0
owledge and belief that the information I provided is true and t?lt I pediment exists
-" 22. SIGNATURE OF BRIDE ~ I
1ST
2ND
3RD
4TH
I duly swear/affirm. dep.ose a
as to my right to enter into
21. SIGNATURE OF GROOM
U
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
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
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.CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Jo C. Ma terson
{ /0 TIME MONTH YEAR MONTH
SEAL , SIGNATURE ~ "-: DATE 11/12/2009
'-v-' MAI~~G~r8al~ ush Rd, Wappingers Falls, NY 12590 11:56AM 11 13 2009 01 11 2010
STREET CITYITOWN STATE ZIP PM
~~~R~~Ri~~J IO~O~:N~ZJ~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TI EM. DAY YEA 0 0 ,RELIGIOUS 1 ~CIVIL
DATE AND AT THE TIME AND /K'JLO
PLACE INDICATED. I.J.!' PM 5" 0 9 0 OTHER, SPECIFY
'tJeJJ t s: i- tJNCESI!
YEAR
28. PLACE WHERE MARRIAGE OCCURR~
() tct/€.SS
A. STATE NEW YORK B. COUNTY
C.
29. OFFICIANT
NAME (PRINT)
SPECIFY