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COUNTY DLJtchA~~
CITY/TOWN Wappinger
~~~:~; 1 368 .
~5~~J~R 82
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
AI~gnn AI\larez, C~fieNTSURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Yi
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.IFmnifAr Ann RI::tkA
MIDDLE CURRENT SURNAME
.-J
1 . A FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 ?3-7()-~3fi?
2. RESIDENCE A. NXTATE) B. 9dd~E'9S
C. CHECK ONE 0 CITY oIZI TOWN 0 VILLAGE
~~~CIFY Fi~hkill
D. STREET ADDRESS 65 Ward Place ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 25 3B. DATE OF BIRTH MOj,t / 2~ / y1~R3
4. EMPLOYMENT
A. USUAL OCCUPATION Pc TAr.hnir.i::tn
B. TYPE OF INDUSTRY OR BUSINESS School District
5. PLACE OF BIRTH ~I~~~;';'E /~dGNTRY IF NOT USA)
6. FATHER
A. NAME AlhArt AI\I::trA7 Sr
B. COUNTRY OF BIRTH Puerto Rico
7. MOTHER
A. MAIDEN NAME Marie Esther Solis
B. COUNTRY OF BIRTH PIJerto Rico
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE A h/:;I re7
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER 072-68-3408
12. RESIDENCE A. NY B. nlltchA~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY IZl TOWN 0 VILLAGE
~~CIFY Fishkill
D. STREET ADDREss65 Ward Place
ZIP 12524
o YES~ NO
A~R3
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 26 3B. DATE OF BIRTH OR A'l?
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Pre-~chool Teacher
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTH ~!~~~~E / ~~NTRY IF NOT USA)
16. FATHER
A. NAME Allen Ronald Blake
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Christine Ann Ranalli
B. COUNTRY OF BIRTHU S A
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?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
,.- YEAR
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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
21. SIGNATURE OF GROOM~
o 0 1ST 0 0
o 0 ~D 0 0
o 0 ~D 0 0
o 0 4TH 0 0
e and belief that the Information I provided is true and that I declare that no legal impediment exists
22. IGNATURE OF BRIDE ~t5/)'/ ryJ IJ...R 1. .br~ ~
U!ll:{9URAENT NAME "-
DATE 08/03/2009
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23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE
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 ~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
by New York Domestic
,-I-.,
{ SEAL }
'-.,,-I
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
SIGNATURE ~
MAILING ADD S
20 Mi d
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
AM
03:24PM
02 2009
08
04
2009
10
1~IVIL
28. PLACE WHERE MARRIAGE OCCURRE~
A. STATE NEW YORK B. COUNTY y:."f; r~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF )&., TOWN OF 0 VILLAGE OF
SPECIFY W~//I'tJ.6:.e.,
"'. W",,""~ON'
",.,,'"'""~.~..t (!Oi-I1Bbt w
SIGNATURE~ ,~;F~
NAME (PRINT)
SIGNATURE~