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;) I A I ~ VI"" 1'4~VV YVM~
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Fdnar Edmundo Vazauez
'" MIDDLE CURRENT SURNAME
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 marrrage state. / ~
21. SIGNATURE OF GROOM~.CJ~~.,r (/A2 aV c.1:' . 22. SIGNATURE OF BRIDE~ ~)?11'; "JR~ .7-~.uU?
USE NT NAME I n I us UR ENT E
23. SUBSCRIBED AND SWORN TO/AFFIR ED BEFORE ME '111 I J 10/17/2008
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 perlorm marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
Iltlf 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) Jo C. Mast rson
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ DATE 10/17/2008
MAILING ADORES AM
'-.t-I 20 Middle ush Rd. Wappinqers Falls, NY 12590 03:54PM 10 17 2008 12 15 2008
STREET CITYrrOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER. ./
SONS NAMED ABOVE ON THE DAY YEAR 00 RELIGIOUS 1 [l?'CIVIL
DATE AND AT THE TIME AND '1_~
PLACE INDICATED. 0"'V3' 9 0 OTHER, SPECIFY
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~~ 1368
~~~I~J~R 161
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER 062-92-8707
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY..tJ TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 1062 Route 9; Apt 2 ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'6 NO
11 /02 /1978
MONTH DAY YEAR
3. A. AGE ?~
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Cook
B. TYPE OF INDUSTRY OR BUSINESS Restaurant
5. PLACE OF BIRTH Luis Cordero. Ecuador
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Sp.gLmdo Carlos Vazquez
B. COUNTRY OF BIRTH Ecuador
7. MOTHER
A. MAIDEN NAME Margarita Rivas
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
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
SIGNATURE~
DOH.9B (03/2006)
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Fannv Beatriz Vazquez
MIDDLE CURRENT SURNAME
-1
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEl091_96_3460
D. SOCIAL SECURITY NUMBER
12, RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 1062 Route 9; Apt 2
ZIP 12524
DYES '6 ND
;t'981
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE?
13. A, AGE 27 3B. DATE OF BIRTH 07 /f 1
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS DCC
15. PLACE OF BIRTH Luis Cordero, Ecuador
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Teofilo Florencio Vazquez
'B. COUNTRY OF BIRTHEcuador
17. MOTHER
A. MAIDEN NAME Leonor Cedillo
B. COUNTRY OF BIRTHEcuador
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
~ YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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
YEAR
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY uvT~~a.:>
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF [l?'1-0WN OF 0 VILLAGE OF
SPECIFY WAPPuJGf:~
NAME (PRINT)
SIGNATURE~