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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Anrlrp.w Mir.h::lp.1 nnn::lhllp.
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c; 1368 '
~5~1~~~R 81
1. A. FULL NAME
FIRST
0..
F;j
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 008-72-2091
2. RESIDENCE A. NY B. nlltr:hp.!=:!=:
(STATE) (COUNTY)
C. CHECK ONE D CITY D TOWN ~ VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 797 Old Route 9 North. Apt.zIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? f!'1 YES D NO
3. A. AGE ?~ 3B. DATE OF BIRTH 1? /?4 / 1 QR!1
MONTH DAY YEAR
4, EMPLOYMENT
A. USUAL OCCUPATION F::lr.i1ityTer.h
B. TYPE OF INDUSTRY OR BUSINESS Target
5. PLACE OF BIRTH Hartford, Conn
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Timothy A Donahue
B. COUNTRY OF BIRTH USA
7, MOTHER
A. MAIDEN NAME Tess Barlett
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
c. DATE LAST MARRIAGE ENDED?
(2) D DEATH
(3) D ANNULMENT
/ /
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) (CITYICOUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I
"I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jade Fernandez
MIDDLE CURRENT SURNAME
-.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Fp.rn::lndez-Donahue
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 060-70-0272
12. RESIDENCE A. NY 8 Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY D TOWN'll VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 797 Old Route 9 North, Apt. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? tJ YES D NO
/'15 A985
DAY YEAR
13. A. AGE ?4
01
MONTH
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OOCUPATION Home Maker
B. TYPE OF INDUSTRY OR BUSINESS Home Maker
15. PLACE OF BIRTH Bronx. Nv
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Michael R. Fernandez
'B. COUNTRY OF BIRTHU SA
17. MOTHER
A. MAIDEN NAME Gisele 1.. SaQarra
B. COUNTRY OF BIRTH USA
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END?
(3) D DIVORCE
(3) D ANNULMENT (2) D DEATH
/ /
. '. - YEAR
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
D D 1ST
D D 2ND
D D 3RD
D 4TH
ge and belief that the information I provided is tr
D
D
D
1ST
2ND
3RD
4TH
I duly swear/aHinn, depose and say
as to my right to enter into the ma a
21, SIGNATURE OF GROOM~
23. SUBSCRIBED AND SWORN TO/AFFIRMED 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 ~11 to perfonn marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY,
D 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
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{ } NAME (PRINT)
SEAL SIGNATURE ~
"-v-I MAI~~ tJi?
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
<r DATE 07/30/2009
in ers Falls, NY 12590
CITYITOWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 ~RELIGIOUS
IS ~09 9 D OTHER, SPECIFY
by New York Domestic
TIME
MONTH
MONTH
YEAR
YEAR
AM
03:22PM
2009 09
28 2009
07
31
1 D CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYblAUfte55
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF arTOWN OF D VILLAGE OF
SPECIFY W /1..PPj N ~e. ~ .
SIGNATURE~