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COUNTY Dutchess
CITYfTOWN Wappinger
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~5~I;J~R 174
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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Juan Marcos Zambrano
MIDDLE CURRENT SURNAME
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Florencia Salvina Duque
MIDDLE CURRENT SURNAME
.J
1. A. FUll NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Zambrano
(OPTIONAL - SEE REVERSE) 1 04-94-0090
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY Wappin~ers Falls
D STREET ADDREss26 pring Street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
/14 ,A980
DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)080 96 7530
D SOCIAL SECURITY NUMBER --
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWNo{] VILLAGE
~~~CIFY Wappinqers Falls
D. STREET ADDRESS 26 Spring Street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
10 /26 /1981
MONTH DAY YEAR
02
13 A. AGE 28
3. A. AGE 27
3B. DATE OF BIRTH
3B. DATE OF BIRTH
MONTH
t-
:>
<C
4. EMPLOYMENT
A. USUAL OCCUPATION Maintenance
B. TYPE OF INDUSTRY OR BUSINESS Apartment
5. PLACE OF BIRTH Chone, Manabi. Ecuador
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME John Marcos Zambrano
B. COUNTRY OF BIRTH Ecuador
7. MOTHER
A MAIDEN NAME Mirian Aracelv Rodriauez
B. COUNTRY OF BIRTH Ecuador
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Health Care Provider
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH Giron, Azuay, Ecuador
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Julio Abdon Duque
'B. COUNTRY OF BIRTHEcuador
17. MOTHER
A. MAIDEN NAME Maria Gerardina Sari
B. COUNTRY OF BIRTH Ecuador
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
II:
W
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o 0
o 0
o 0
o 0
no legal impediment exists
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is~,rue , hat I .de
as to my right to enter into the marriage state. . ---z/--:l?'
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF BRIDE~ /
USE CURRENT NAME
DATE
11/21/2008
23. SUBSCRIBED AND SWORN TO/AFFIRMED BE RE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in Ne York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11to 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) Joh ,C. Ma
{ / ' TIME MONTH YEAR MONTH
SEAL SIGNATURE~ , ~/.", DATE 11/21/200
MAILING ADDRESS AM 11 22 2008 01 20 2009
~ STRte9 Middl ush Rd. WaD~~~~~rs Falls'sT~r 1259~p 12:46PM
~~~R~:RT~~~ IO~O~~~N~ZEEf. 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~ RELIGIOUS
DATE AND AT THE TIME AND M
PLACE INDICATED. 3;3 M /2 0," " ~ 9 0 OTHER, SPECIFY
~ . t0olPrr\
t.f1~
~
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY l)u-tc.k"s
29. OFFICIANT ~...." D
NAME (PR~ V'^-'
SIGNATUR~ Q...La...( &
MAILING ADDRESS,
'2.."~ S~
STREET
30. WITNESS TO ~MONY
NAME (PRINT) ,1.. tf!5c.
TITLE rOo ~ +e R-
DATE '2..140l c. t':o ~ '
STATE ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) N tft:Dt::.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
I): CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY ~ C. 1.:)1'"\
CITYfTOWN
'4
Vod v~ V' \.
'QvC
f';f 1Lt
SIGNATURE~
DOH-98 (03/2006)
SIGNATURE~!