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COUNTY Dutchess
CITYffOWN Wappinger
~~~:~c~1368
~G~I:~~R167
.." . '" I ... "'. I .. ... Y Y I '" I~ .'-
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FrlO;:lr ~~~lmdn V~~R~~~~RNAME
(fH/1:; I:;!'AC;c t-UH I:;/A/I: ViiI: UNLYj
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Fanny Beatriz Vazquez
MIDDLE CURRENT SURNAME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
..
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEb91 96 3460
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE ANY B.Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY..o TOWN 0 VILLAGE
~~~cIFYFishkill
D. STREET ADDRESS1 062 Route 9; Apt 2
ZIP 12524
DYES f:J NO
;1'981
YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEb
o SOCIAL SECURITY NUMBER 62-92-8707
2 RESIDENCE A. NY B. nlltr:hess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY~ TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 1 062 Route 9: Apt 2 ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YEsYO NO
3. A. AGE29 3B. DATE OF BIRTH 11 / n? /1978
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE27 3B. DATE OF BIRTH 07 )1'1
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Cnnk
B. TYPE OF INDUSTRY OR BUSINESS Restaurant
5. PLACE OF BIRTH I I lis Cnrdero, Ecuador
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Segllndo r.~rlm:: \!;:l7rp le7
B. COUNTRY OF BIRTH Fr:uadnr
7. MOTHER
A. MAIDEN NAME M;:lrg;:lrita Rivas
B. COUNTRYOFBIRTH Fr.IJ;:lrlnr
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
14. EMPLOYMENT
A. USUAL OCCUPATIONStudent
B. TYPE OF INDUSTRY OR BUSINESS DCC
15. PLACE OF BIRTHLuis Cordero, Ecuador
(CITY , STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Teofilo Florencio Vazquez
'B. COUNTRY OF BIRTrEcuador
17. MOTHER
A. MAIDEN NAME Leonor Cedillo
B. COUNTRY OF BIRTrEcuador
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
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH OA Y
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
cr:
W
III
::IE
::>
z
c
z
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cr:
lii
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
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 declare that no legal impediment exists
as to my right to enter into the marriage state. ~
21. SIGNATURE OF GROOM.' td~<4.1 ~~Li 22. SIGNATURE OF BRIDE. r.nnl1Y J ~-7~./~ 2.
US ENTNA E / USE~NTN
23. SUBSCRIBED AND SWORN TO/AFFIR 0 BEFORE ME {i..... 1 0/24/2008
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the~rriage in New ork State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform m riage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
" 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) ~~~
SEAL SIGNATURE~ Lc.~ DATE 10/?4/?008
MAILING ADDRESS
"-v-' STR?>> MirlrllF!RII~h Rd, WarR~~~rs Falls'ST~r 1259~p
~~~R~~RT~~~ IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. E OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR
DATE AND AT THE TIME AND
PLACE INDICATED. . 0 PM
I.'l.\'.rr~~:m LL R ~ ~ tJ ~ t i A ~ 0 .
SIGNATURE~llp. '(U.Ll e.v.,c..o
MAILING ADDRESS
IgJi SuYDAM Sf' ~OD,^L~lf
STREET CITYffOWN
TIME
MONTH
YEAR
MONTH
YEAR
09:08AM
PM
10
24
2008
12
22 2008
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY tA i 31 e S
10 CIVIL
TITLE ~Ot1^tI. CAi{fol.'c Pai
DATE i 0 /2' { 0 r;
btr
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
c:oI6lTY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY_B RooiA L i{ H'
STATE
HH(
ZIP
31. WITNESS TO CEREMOtlY
c 0 Ro HlbLl
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-98 (03/2006)
SIGNATURE~