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couNnDutchess
CITYrrOwNWappinger
~~~:~CR't 368
REGISTE~
NUMBER
::>> I A II: U'" I~E: VV J UM~
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Otto \I1~rlimir Vogrincic
MIDDLE CURRENT SURNAME
FIRST
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jennifer Fabiola Carrillo
MIDDLE CURRENT SURNAME
~
1. A FULL NAME
11. A. FULL NAME
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C SURNAME AFTER MARRIAGE Voqrincic
(OPTIONAL' SEE REVERSE577 -43-3798
D. SOCIAL SECURITY NUMBER
12 RESIDENCE ANY BDutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITYoorJ TOWN 0 VilLAGE
~~~CIFYWappinger
D. STREET ADDRESs16 E Winthrop Court
ZIP 1209U
o YES....O NO
)985
YEAR
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER XXX-XX-XXXX
2 RESIDENCE A. NY B nlltr.he!=:!=:
(STATE) (COUNTY)
C. CHECK ONE 0 CIT'r\o'O TOWN 0 VilLAGE
AND \^' .
SPECIFY ~rrJnOAr
D STREET ADDRESS 16 E Winthrop Court ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEs"'b NO
10 /07 /1986
MONTH OA Y YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE23 3B. DATE OF BIRTH 07 ,2'3
MONTH DAY
3. A AGE22
3B. DATE OF BIRTH
4. EMPLOYMENT
A USUAL OCCUPATION Stlldl"nt
B. TYPE OF INDUSTRY OR BUSINESS Frlllcation
5. PLACE OF BIRTH~af?v~J-iA;~i/1~uQ1R~ !t~~~C~ZY
6. FATHER
A. NAME Alberto ~aigl lei \/ogrincir.
B. COUNTAY OF BIRTH Iln 'OII;:!Y
7. MOTHER
A MAIDEN NAME SlllIy l\A::lriAII::l r.llrheln
B. COUNTRY OF BIRTH Iln IO'I::lY
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
14. EMPLOYMENT
A. USUAL OCCUPATIONStudent
B. TYPE OF INDUSTRY OR BUSINESsEducation
15. PLACE OF BIRTHHuacho, Peru
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEMarcos Pedro Carrillo Rubio
. 8. COUNTRY OF BIRTt-feru
17. MOTHER
A MAIDEN NAME Fabiola Amalia Peredes De Carrillo
B. COUNTRY OF BIRTt-feru
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
o
o
o
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (,
MONTH 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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say,
as to my right to enter into the m
o 0
o 0
o 0
o 0
'mpediment exists
W
en
z
W
u
:i
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
hat to t~~ st of my knowledge and belief that the information I provided is true and tho at I declare that no Ie
~st.attl, \
,.. ,. .7' I ~ '.
. I\A' . . /22. IGNATURE OF BRIDE. '.
U CU ~NT NAME . USE CURRENJ::!IA~
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME I "--'<l' 02/06/2009
SIGNATURE OF TOWN OR CITY CLERK~ DATE
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 !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
21. SIGNATURE OF GROOM.
~
{ SEAL}
'-v-I
NAME (PRINT)
MONTH
YEAR
YEAR
TIME
MONTH
AM
02:43PM
02
07
2009
04
07 2009
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~ U, G-t,k~
C. LOCATION OF CEREMONY
(CHECK ONE AND }pECIFY)
o CITY OF ar40WN OF 0 VilLAGE OF
SPECIFYW4PfJ I ~
SIGNATURE~
DOH.9B (0312006)
ZIP
31. WITNESS TO C':rE~NY
NAME (PRINT) /'-1 ~
SIGNATURE~
--