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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Nicholas Michael Matthews
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinqer
~~~~~: 1368
~~~I:~~R 14
1 . A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 094-70-9216
2 RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY..tJ TOWN 0 VILLAGE
AND W .
SPECIFY apptnQer
o STREET ADDRESS 16 Brown Rd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'6 NO
1? /01 /1985
MONTH DAY YEAR
3. A AGE23
3B. DATE OF BIRTH
4. EMPLOYMENT
A USUAL OCCUPATION Rll!=; nriver
B. TYPE OF INDUSTRY OR BUSINESS Transportation
5. PLACE OF BIRTH Reacon, NY
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME KF>\lin .In!=:erh Matthew!'; Sr
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Patty Ann GallaQher
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) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
( I HI::; ::;/-'A(;/= rUH ::; , A 1/= U::;t= UNL YI
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Ana Jesus Martinez Perez
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Matthewmartinez
(OPTIONAL. SEE REVERS~n..
D. SOCIAL SECURITY NUMBER X1U\.- XX - XXXX
12 RESIDENCE ANY BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY '6 TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 16 Brown Rd
ZIP 12590
o YES '6 NO
)"978
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A AGE30 3B. DATE OF BIRTH 12 ~5
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Auto Detailer
B. TYPE OF INDUSTRY OR BUSINESS Auto
15. PLACE OF BIRTHAyacuchu, Peru
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Emilio Martinez Mensoza
'B. COUNTRY OF BIRTHPeru
17. MOTHER
A MAIDEN NAME Carlota Perez Galvez
B. COUNTRY OF BIRTHPeru
18. 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) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
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
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swearlaffirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and th t I dllclare
as to my right to enter into the marriage state. -
21. SIGNATURE OF GROOM.
o 0
o 0
o 0
o 0
hat no legal impediment exists
USEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED 8EFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes 1he marriage in New York State of the bride and groom named above by any person authorized
Relations Law !l11 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
~
{ SEAL}
'-v-I
NAME (PRINT)
ITY
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
10: 30 ~M L{
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
3 0/00'1
~~n~~:m J~_C ~~sT'~:n
SIGNATURE~ _c'ftl~~.-
MAILING ADDRESS
~C; M)~~USI.{ ~; ()Ji,PP,iJ6EP.-"
STREET CITYfTOWN
30. WITNESS TO CE
{411S
OATE
03/26/2009
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
10:15AM
PM
03
27
2009
05
25 2009
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY t:. u TC.lt{e~s,
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 60WN OF 0 VILLAGE OF
SPECIFY W.4,.pP IN6 E (Z
SIGNATURE~