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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~c: 1 368
~5~I:J~R 44
~ I A I t: Ur- I~t: VV J UMI'\
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Hector Ruben Carrazco
MIDDLE CURRENT SURNAME
FIRST
(THIS SPACE FOR STATE USE ONL Yi
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Maria Antonieta Terreros
MIDDLE CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Carrazco
(OPTIONAL - SEE REVERSE)139_17 -7 512
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY B Dutchess
(STATE) J.. (COUNTY)
C. CHECK ONE 0 CITY Q TOWN U VILLAGE
~~CIFY Wappmgers Falls
o STREET ADDRESS3 Park Ave. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 1] YES 0 NO
13. A. AGE32 3B. DATE OF BIRTH 09 ;f.7 ~76
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER xxx-xx-xxxx
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWNI{] VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 3 Park Ave. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
02 /02 /1980
MONTH DAY YEAR
3. A. AGE 29
3B. DATE OF BIRTH
~
:>
<C
4. EMPLOYMENT
A. USUAL OCCUPATION Handyman
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH Mendoza, Argentina
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Juan Manuel Carrazco
B. COUNTRY OF BIRTH Argentina
7. MOTHER
A. MAIDEN NAME Gloria Argentina Toledo
B. COUNTRY OF BIRTH Argentina
6. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATION Housewife
B. TYPE OF INDUSTRY OR BUSINESS HouseWife
15. PLACE OF BIRTH Cuenca, Ecuador
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Ruben Dario T erreros
'B. COUNTRY OF BIRTHEcuador
17. MOTHER
A. MAIDEN NAME Ana Maria Zeas
B. COUNTRY OF BIRTHEcuador
18. NUMBER OF THIS MARRIAGE 3
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT DEATH DIVORCE CIVIL ANNULMENT
1 0 0 2 0 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEAJH B. HOW DID LAST MARRIAGE END? (3) i1 DIVORCE (3) 0 ANNULMENT (~D DEATH
C. DATE LAST MARRIAGE ENDED? 07 / 27 / 2007 C. DATE LAST MARRIAGE ENDED? 01 / 25 / 20u8
MONT~ DAY YEAR MONT~ DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? [J YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
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) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH. DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
07/27/2007 Westchester, New York 0 r1 1ST 01/25/2008 Westchester, New York 0 t:i
o 0 2ND 05/03/2005 Cuenca, Ecuador ~ 0
o 0 ~D 0 0
o 0 4TH 0 0
it of my knowledge and belief that the information I provided is true a that I declare that no legal impediment exists
2. SI ATURE OF BRIDE ~
DEATH
21. SIGNATURE OF GROOM~
USE CURRENT NAME
05/19/2009
USE CURRE
23. SUBSCRIBED AND SWORN TO/AFFIR 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 purpose of a second Dr subsequent ceremony.
r-I'-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) J C Ma terson
TIME MONTH YEAR
SEAL SIGNATURE" ' ATE
'-v-I MA~~GIOW~ sh Rd, Wa
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE
by New York Domestic
MONTH
YEAR
02:21:~ 05
18 2009
2009
07
20
l~CIVll
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~/i)Gt!::.
29. OFFICIANT
NAME (PRINT)
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
It( CITY OF 0 TOWN OF 0 VilLAGE OF
SPECIFY ;V e:t:ul.:s( lIP a. It
SIGNATURE"
DOH-98 (0312006)
NAME (PRINT)
SIGNATURE"
:PC>
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