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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Juan Carlos Morales
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT Morales Martinez
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:kc~1368
~~~I:~~R6
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Linda Joanne Flores
1. A. FULL NAME
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)-83_67 -4760
D. SOCIAL SECURITY NUMBER 0
2. RESIDENCE A NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY..o TOWN 0 VILLAGE
~~~CIFY PouQhkeepsie
D. STREET ADDRESS 120 Channingville Rd. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY DR INCORPORATED VILLAGE? 0 YES 1J NO
07 /23 /1979
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE'134-70-3541
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY BDutchess
(STATE).L (COUNTY)
C. CHECK ONE [J CITY U TOWN 0 VILLAGE
~~~CIFYPougIiKeepsle
12U Ghannmgvllle Ka. -12590
D. STREET ADDRESS ZIP 01
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 Y)-97 40
13. A AGE34 3B. DATE OF BIRTH 09 )1'7 _
MONTH DAY YEAR
3 A AGE29
38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Butcher
8. TYPE OF INDUSTRY OR BUSINESS Wholesale Club
5. PLACE OF BIRTH MayaQuez, Puerto Rico
(CITY, STATE / COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Register Nurse
8. TYPE OF INDUe TRY O'SBUSINESS Health Care
15. PLACE OF BIRTH old pring, New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A NAME Santos Morales
8. COUNTRY OF BIRTH Puerto Rico
7. MOTHER
A. MAIDEN NAME MarQarita Esther Martinez
B. COUNTRY OF BIRTH Puerto Ricci
8. NUMBER OF THIS MARRIAGE 1
16. FATHER
A. NAMEMario Flores
B COUNTRY OF BIRT~uerto RIco
17. MOTHER
A. MAIDEN NAME Lydia Josefa Vazq uez
B. COUNTRY OF BIRTHPuerto RIco
18. NUMBER OF THIS MARRIAGE 2
w
en
z
w
o
:::i
19. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEI1TH
1 0 U
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH 8. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT do~ DEATH
c. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 09 / 12 / 2
MONTH DAY YEAR MONT~ DAY ~ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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, STATE/COUNTRY,IF NOT USA) SELF SPOUSE (MONTH. DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 09/12/2002 Poughkeepsie, New York ~
2ND 0 0 2ND 0
3RD 0 0 3RD 0
4TH 0 0 4TH
I duly swear/affirm, de,:>ose and say, that to the best Of~y knowl dge and belief that the Information I provided is true
as to my right to enter into the mam ge state.
21. SIGNATURE OF GROOM ~ . 22. SIGNATURE OF BRIDE ~
USE RENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIR D 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 by New York Domestic
Relations Law ~11 to pertorm 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.
r-"-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) John C. Masterson
{ ~ TIME MONTH YEAR MONTH
SEAL SIGNATURE ~. DATE 02/09/2009
MAILING ADDRESS 10:03AM 10 2009 04 10 2009
'-.,-I 20 Middlebush Rd, WappinQers Falls, NY 12590 PM 02
STREET CITYITOWN STATE ZIP
~~~R~~~RT:-~ 10~O~~~N~zi~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR J, CIVIL
DATE AND AT THE TIME AND ..:::J;JIl '. 'J""!
PLACE INDICATED. '2.: f; PM' f
} ,
~~~:(~9i~~1 V~
SIGNATURE~ //bm~ DATE
~i'~~~~ttZ R.., t{fftpPI~~ ~
STREET CITYfTOWN
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNTY.p()T'C-If~~
/0
Ni~
I STATE
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY ~FJd TO~N ~F t( VILLAGE OF
SPECIFy!/tIlPfJP iiv' r.3B:6-rrrU6
F .Lo!C;;' &'
SIGNATURE~
DOH-98 (03/2006)
/'