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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Daniel Alejandro Blanco
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYrrOWN Wappinger
~~~:k~ 1368
~5~~J~R 152
1. A. FULL NAME
FIRST
a.
N
8. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEl094_66_7619
o SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) J.. (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFY Beekman
o STREET ADDRESS 29 Indian Pass
12582
ZIP
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VilLAGE? 0 YES,] NO
3. A. AGE 28 3B. DATE OF BIRTH 05 / 05 /1980
MONTH DAY YEAR
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II)
4. EMPLOYMENT
A. USUAL OCCUPATION Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Automotive
5. PLACE OF BIRTH Bronx, Ny
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Enrique Jose Blanco
B. COUNTRY OF BIRTH Cuba
7. MOTHER
A. MAIDEN NAME Leticia L. Rios
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
DEbTH
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
- --
(TH/S SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kerri Lee Milstein
~
11. A. FUll NAME
CURRENT SURNAME
FIRST
MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Blanco
(OPTIONAL - SEE REVERSE)127 -72-807 4
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STATE).L (COUNTY)
C. CHECK Otlli' 0 CITY U TOWN 0 VILLAGE
~~~CIFY tseekman
D. STREET ADDRESs2~ Indian t-'ass
.,
YfiBoO
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13.A. AGE28 3B.DATEOFBIRTH 03 ~5
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF IND4&.TflY.pR ~::>INESS education
15. PLACE OF BIRTH vvnlte larns, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Lee David Milstein
. B. COUNTRY OF BIRTHU S A
17. MOTHER K AM' F'I' .
A. MAIDEN NAME aren nn ane Ilppl
B. COUNTRY OF BIRTHU S ~
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D100RCE CIVIL A~ULMENT
D11TH
(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
22. SIGNATURE OF BRIDE"
1ST
2ND
3AD
4TH
I duly swear/affirm, depose and
as to my right to enter into the
21. SIGNATURE OF GROOM
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
ledge and belief that the information I provided is true
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TITLE
DATE
N tl).) " ORI<
STATE
23. SUBSCRIBED AND SWOR O/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Y 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 crr'( qERKC M 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) J nn. sterson
{SEAL SIGNATURE ~ . - DATE 10/01/2008 TIME MONTH YEAR MONTH
'-.t-I MAI~~~Pd ,Wappingers Falls, NY 12590 06:59~~ 10 02 2008 11 30 2008
STREET CITYrrowN STATE ZIP
~~~R~~Ri~~J lo~Oi~~N~~~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR o~ RELIGIOUS
DATE AND AT THE TIME AND c,.., AM M
PLACE INDICATED. / :.;>1) -fi1Qf I 0 .. 19 - ~ 9 0 OTHER, SPECIFY
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF a VILLAGE OF
SPECIFY LhC,RFllVt.XLV I LU2..
NAME (PRINT)
SIGNATURE~