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COUNTY Dlltchess
CITYfTOWN \^'appinger
~~~:f; 1368
~G~~~~R150
:s I A I t: Ut- Nt:W YUHK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
GMJ~rmo LOP~RENT SURNAME
.;oJ I '"' I ~ rU..~ I..umg~n
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~lliIlArmin::l f:nrtp.7
MIDDLE CURRENT SURNAME
.-J
1. A. FUll NAME
11. A. FUll NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. S~S~~m:N~~~~~t~~b~~~pre7
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A NY
(STATE)
C. CHECK ONE olJ CITY D TOWN D
AND P hk .
SPECIFY nug eepsle
o STREET ADDRES~6 Pershing Ave: FI3 ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ..0 YES D NO
/'111 ;(q79
DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. D("tf"he, ss
(STATE) collmY
C. CHECK ONE .,lJ CITY D TOWN D VILLAGE
AND blJ'
SPECIFY POllg P.eep~IP
D STREET ADDRESS FiR pp.r~hing AVA: FI3 ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? otJ YES D NO
M~~ / ~~ / ~E~16
Bnlltchp.ss
(COUNTY)
VILLAGE
3B. DATE OF BIRTH
11
MONTH
13. A. AGE28
3. A. AGE 32
4. EMPLOYMENT
A. USUAL OCCUPATION Llilndscaper
B. TYPE OF INDUSTRY OR BUSINESS I ::lnrl~r.::lpino
5. PLACE OF BIRTH \/er~crJ IZ Mevir.n
(CITY, STATE / C6UNTRY IF NOT USA)
6. FATHER
A. NAME Ju.n Lope:4
B. COUNTRY OF BIRTH I\Ap'X'ir.n
7. MOTHER
A. MAIDEN NAME CAli::l Hprn::lnrlA7
B. COUNTRY OF BIRTH I\IIA'X'ir.n
8. NUMBER OF THIS MARRIAGE 1
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION LJ npmplnypd
B. TYPE OF INDUSTRY OR BUSINESS Unemployed
15. PLACE OF BIRTHE'uebla, Mexico
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME GII::lrl::iillpP. f:ortp.z
'B. COUNTRY OF BIRTrMexico
17. MOTHER
A. MAIDEN NAME Juana Garcia
B. COUNTRY OF BIRTrMexico
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
[) 0
DEATH
o
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
n
(2) D DEATH
B. HOW DID LAST MARRIAGE END?
(3) D DIVORCE
(3) D ANNULMENT (2) D DEATH
/ /
- YEAR
o
o
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
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
w
en
z
w
o
:i
1ST D D 1ST D D
2ND D D 2ND 0 D
3RD D D 3RD D D
4TH D D 4TH D D
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 marnage state,
r r f ~
21. SIGNATURE OF GROOM~ ,V- I 22. SIGNATURE OF BRIDE~V /11 e7'S VII iliac. (t'!J "IT,... .z
USE C USE CURRENT NAME
23 ~:J..f,.~=~DO~~O~06'~ 6~Abr~RMi~ BEFORE ME DATE 1 % 1/2008
This license authorizes the marriage in New k 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.
D 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
~
{ SEAL }
'-v-I
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
DATE 1 % 1/2008
NY 12590
STATE ZIP
27. TYPE OF CEREMONY
o D RELIGIOUS
9 D OTHER. SPECIFY
11 :09AM
PM
10
02
2008
11
30 2008
F
ITY WN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
AM I J\ '1/. 08
12:,;:,; .~. v l/\C
1~VIL
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY b II nv{e S)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF ~OWN OF D VILLAGE OF
,~,~~::;r ;t; ~v ~'\
SIGNATURE ~ >I.- - / ' .
MAILING ADDRESS '
aO ,.,'.li'''' 's~ i<;~ Io1tt1'O'N6~i
STREET ' CITYfTOWN
3D. WITNESS TO CEREMONY
NAME (PRINT) ;:::. /../ f.
TITLE ,11l1~.f A6E. C)'-C I cE.R-
DATE.Jl2[ <of 2.L{;)Y
h4llS rJ'f I~Y9D
I
SPECIFY
w A-rP I 106 E.fl..-
STATE
NAME (PRINT)
SIGNATURE~