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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Cristi~?oD~edina Sac~~~~~~RNAME
COUNTY Dutchess
CITYfTOWN WappinQer
~~~:~c: 1368
~~~~~~R 56
1. A. FULL NAME
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)5 24 2856
D SOCIAL SECURITY NUMBER 83- -
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOwNIO VILLAGE
~~~CIFY WappinQers Falls
D. STREET ADDRESS 5515 Princess Circle ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? '6 YES 0 NO
12 /05 /1948
MONTH DAY YEAR
3. A. AGE 60
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Car Detailer
B. TYPE OF INDUSTRY OR BUSINESS Automotive
5. PLACE OF BIRTH Yabucoa, Puerto Rico
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Eleuterio Medino
B. COUNTRY OF BIRTH Puerto Rico
7. MOTHER
A. MAIDEN NAME Catalina SantiaQo
B. COUNTRY OF BIRTH Puerto Rico
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
1
(2) {1 DEATH
2009
YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 02 / 09 /
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) (CITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
1 duly swear/affirm, depose an
as to my right to enter into t
21. SIGNATURE OF GROOM
(TH/S SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Maria Pacheco
MIDDLE CURRENT SURNAME
.J
11. A. FULLNAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Medina
(OPTIONAL - SEE REVERSEb83_42_2933
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN"tJ VILLAGE
~~~cIFY~ingers Falls
D. STREET ADDRES;>515 Pnncess Circle ZIp12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ....0 YES 0 NO
)17 )949
DAY YEAR
13. A. AGE60
02
3B. DATE OF BIRTH
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATIONHomecare
B. TYPE OF INDUSTRY OR BUSINEssAfflit Agency
15. PLACE OF BIRTHSan German, Puerto Rico
(CITY. STATE / COUNTRY IF NOT USA)
o
o
o
16. FATHER
A. NAME Rafael Pacheco
'B. COUNTRY OF BIRTtfuerto Rico
17. MOTHER
A. MAIDEN NAME Maria Santiago
B. COUNTRY OF BIRTtfuerto Rico
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (g) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 03 / 21 / 19!:14
MONTt\oI DAY' . - YEAR
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. STATElCOUNTRY. IF NOT USA) SELF SPOUSE
1ST 03/21/1994 Dominican Republic 0 rj
2ND 0 0
3RD 0 0
o 0
al impediment exists
W
UJ
Z
W
(,)
~
~
{ } NAME (PRINT)
SEAL SIGNATURE.
'-v-I MA~~G~~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
USEC
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 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 urpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
03:00~~ 06
11
2009
08
09 2009
1~CIVIL
28. PLACE WHERE MARRIAGE OCCURRT'l\
A. STATE NEW YORK 8. COUNTYUJ Te)f~
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ lOWN OF J( VILLAGE OF
SPECIFY 1{!t9/1?L~g lJrl LS
ZIP
". WITH"" m 9'l'~~ ~
NAME (PRINT) l~. ~jI\ ~ /jt1l0S
SIGNATURE. c . ~