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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ruben Dario Duque
MIDDLE CURRENT SURNAME
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 06 / 01 / 2005 '
MONT~ 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
06/01/2005 Poughkeepsie, Ny 0 r5 1ST
o 0 2ND
o 0 3RD
o 0 4TH
! my knowledge and belief that the information I provided is true an
US
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE. OF TOWN OR CITY CLERK~
This license authorizes the marriage in New rk State of the bride and groom named above by any person authorized by New York Domestic
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 (PRINn J hn C. Masterson
{ l TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ .,' ~ DATE 10/20/2008
"-v-' MA~5G~&'j, ush Rd, Wappingers Falls, NY 12590 02:57~~ 10 21 2008 12 19 2008
STREET CITYrrOWN STATE ZIP
~~~R~:Ri~~~ 'o~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY _/
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 [Q' CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 10 2i door 90 OTHER. SPECIFY
COUNTY Dutchess
CITYfTOWN Wappinger
DISTRICT1368.
NUMBER
REGISTER 162
NUMBER
1 . A. FULL NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) XXX-XX-xxxx
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY"lJ TOWN 0 VILLAGE
D. :~:~~AD:E::c~~~e~nncess Circle ZIP 12b90
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
03 /31 /1977
DAY YEAR
3. A. AGE 31
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Cleaner
B. TYPE OF INDUSTRY OR BUSINESS Cleaning
5. PLACE OF BIRTH Tulua, Colombia
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Oscar Emilio Duque
B COUNTRY OF BIRTH Colombia
7. MOTHER
A. MAIDEN NAME Martha Ligia Salinas
B. COUNTRY OF BIRTH Colombia
B. NUMBER OF THIS MARRIAGE 2
DEATH
o
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that tcl'the best
as to my right to enter into th~ ~.~nage stre.
21. SIGNATURE OF GROOM~
--"'~
29. OFFICIANT
NAME (PRINn
TITLE
DATE
NAME (PRINn
SIGNATURE~
DOH-98 (0312006)
:SfAIt:. ~ILf: NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Una Maria Lopez
MIODLE CURRENT SURNAME
-.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Duque
(OPTIONAL. SEE REVERSE) XXX-XX - XXXX
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STATE).L (COUNTY)
C. CHECK O~~ . 0 CITY U TOWN 0 VILLAGE
~~~CIFY wappinger
till ~ t-'rmcess L,;lrcle
D. STREET ADDRESS Z'::;'
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE 25 3B. DATE OF BIRTH 08 ):)8
MONTH DAY
'12590
Yfi830
YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Housewife
Housewlte
B. TYPE OF INDU~TRY OR BUS!t:!ES?
15. PLACE OF BIRTH t-'erelra, L,;olombla
(CITY, ST ATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Jairo Lopez
'B. COUNTRY OF BIRTHcolombla
17. MOTHER
A. MAIDEN NAME Dolly Valencia
B. COUNTRY OF BIRTHColombla
1
16. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIOORCE CIVIL AN~ULMENT
DEdTH
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
22. SIGNATURE OF BRIDE ~
o 0
o 0
o 0
o 0
that I declare that no le9f1 impediment exists
,\1\.(1\ d(? -( .
USE CURRENT NAME
DATE 10 0/2008
YEAR
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~11Tc.L-le~<;
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
mA R.~ \ ftGk t4+ ( cft:R....
lof ~1/'J.Or)~
/ I
I~ q{)
STATE ZIP
31. WITNESS TO C REMONY C
NAME (PRINn IC~ ..:n
SPECIFY I.AlA Pf I JJ(,f...({.
SIGNATUR