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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFADAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Migbl~~&nrgel Nun8iAE1WS\JRNAME
o
B. HOW DID LAST MARRIAGE END? (3) I!il'DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 1 ? / 1? /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
1?/1?/?OOR P()[lghkFlFlr~iFl NY 0 [!J' 1ST
o 0 2ND
o 0 3RD
o 0 4TH
wledge and belief that the information I provided is
23. SUBSCRIBED AND SWORN TO/A FI D BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK"
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law !i11 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
COUNTY nlltr.hess
CITYITOWN \/\/::lrrinopr
~~J:~: 11RR '
~5~~J~R ~n
1. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME. IF DIFFERENT
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
+
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 071-6A.-777R
2. RESIDENCE A. N';(TATE) B. I:?c~ess
C. CHECK ONE 0 CITY.{2J TOWN 0 VILLAGE
AND 'AI .
SPECIFY applngE:'r'
D. STREET ADDRESS 9 F PFlmhrnkFl r.irr.lFl ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES otJ NO
MOfMt / DClf / y~66
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Y oJair~,~~~elarelCiel ~6mt'isuRNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER OR5-9?-1250
12. RESIDENCE A. NY B. nlltr.hFl~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY eJ TOWN 0 VILLAGE
AND W .
SPECIFY ::lpplngFlr
D. STREET ADDREss9 F Pembroke Circle
ZIP 12590
o YES~ NO
A'97R
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 30 3B. DATE OF BIRTH 11 /.55
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION ~t~y At HnmFl Mnm
B. TYPE OF INDUSTRY OR BUSINESS Home Maker
15. PLACE OF BIRTH Dominican Reoublic
(CITY, STATE / COUNTRY I~ NOT USA)
16. FATHER
A. NAME ~nn7::lln NI InFl7
. B. COUNTRY OF BIRTHDominican Republic
17. MOTHER
A. MAIDEN NAME Angela Elvira Castellano
B. COUNTRY OF BIRTHDominican Republic
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
3. A. AGE "13
4. EMPLOYMENT
A. USUAL OCCUPATION NY State Police
B. TYPE OF INDUSTRY OR BUSINESS I ::lW F nfnrr.FlmFlnt
5. PLACE OF BIRTH l\11~nh::ltt::ln NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
3B. DATE OF BIRTH
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A. NAME Mig'lel Angel Nllnez
B. COUNTRY OF BIRTH PIIFlrtn Rir.n
7. MOTHER
A. MAIDEN NAME I Ili~::l 1\/I~rtinFl7
B. COUNTRY OF BIRTH PIIFlrtn Rir.n
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,- YEAR
o 0
o 0
o 0
o 0
ped~!s
DATE
by New York Domestic
TIME
1
(2) 0 DEAJH
?OOR
YEAR
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"-v-I
NAME (PRINT)
MONTH
YEAR
YEAR
08/24/2009
NY 12590
STATE ZIP
27. TYPE OF CEREMONY /'
l~CIVIL
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~ .
AM
01 :09PM
23 2009,
08
25
2009.1 0
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~V IC/41.
C. LOCATION OF CEREMONY
(CH~NE AN IFY)
IIiI""C,TYOF
It.
31. WITNESS TO crEM05 n J ~ \... ~ ~
NAME (PRINT) / fl1 e f(:rO .....\ 2~ \) A.t' (' I
. J . , --r- ---::> ./