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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Nicholas Michael Matthews
MIDDLE CURRENT SURNAME
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I de
as to my right to enter into the marnage state.
21.SIGNATUREOFGROOM~ - ~
us
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE M
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 or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) John C. Mas er on
TIME MONTH YEAR
SEAL SIGNATURE~' DATE 01/23/2009
MAILING ADDRESS 10:14AM 01
~ STR~9 Middle sh Rd, Wap~~~;!S Falls'sT~r 1259~p PM
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. PM 9 0 OTHER, SPECIFY
COUNTY Dutchess
CITYITOWN Wappinger
~~~~~:1368
~5~~J~R 2
1. A. FULL NAME
FIRST
0..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEb94_70_9216
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY..a TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS 16 Brown Rd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"6 NO
A. AGE 23 3B. DATE OF BIRTH 12 / 01 /1985
MONTH DAY YEAR
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EMPLOYMENT
A. USUAL OCCUPATION Bus Driver
B. TYPE OF INDUSTRY OR BUSINESS Transportation
PLACE OF BIRTH Beacon. NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Kevin Joseoh Matthews Sr
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Patty Ann Gallagher
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
a:
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STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ana Jesus Martinez Perez
-.J
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Matthewmartinez
(OPTIONAL - SEE REVERSEL__
D. SOCIAL SECURITY NUMBER xxx - xx - XXXX
12. RESIDENCE ANY B. Dutchess
(STATE).L (COUNTY)
C. CHECK ONE [J CITY U TOWN 0 VILLAGE
~~~CIFY WappInger
D. STREET ADDRESS 16 Brown Rd
ZIP 12b!:lU
DYES '6 NO
)'978
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 30 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
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES
DAY
ONO
~
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
o
o
o
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UJ
Z
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29. OFFICIANT
NAME (PRINT)
TITLE
SIGNATURE ~
MAILING ADDRESS
DATE
STREET
30. WITNESS TO CEREMONY
CITYITOWN
NAME (PRINT)
SIGNATURE~
DOH-98 (03/2006)
DATE
01/23/2009
by New York Domestic
MONTH
YEAR
24
2009
24 2009
03
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~