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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
F rA~lg~E X aviAr G 8t~~j~ SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~; 1368
~5~1:~~R 147
1. A. FUll NAME
FIRST
0-
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 DlltchASS
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWNolJ VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 1 Wenliss Terrace: Apt 1 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? tJ YES 0 NO
3. A. AGE 3q 3B. DATE OF BIRTH Ofi / 07 /1969
MONTH DAY YEAR
l-
S;
<(
Q
wi!
~1L
-<(
4. EMPLOYMENT
A. USUAL OCCUPATION Cook
B. TYPE OF INDUSTRY OR BUSINESS Restaurant
5 PLACE OF BIRTH Guavaauil. Ecuador
(CITY, STATE! COUNTRY IF NOT USA)
6. FATHER
A. NAME Ralll Garcia
B. COUNTRY OF BIRTH Ecuador
7. MOTHER
A. MAIDEN NAME Rosa Borja
B. COUNTRY OF BIRTH Ecuador
8. NUMBER OF THIS MARRIAGE 2
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
C. DATE LAST MARRIAGE ENDED? 06/ 23 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? [of 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
06/23/2004 Guayaquil. Ecuador ~
DEATH
o
(2) 0 DEATH
2004
YEAR
w
en
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::::i
29. OFFICIANT
NAME (PRINT)
TITLE
SIGNATURE.
MAILING ADDRESS
DATE
STREET
30. WITNESS TO CEREMONY
CITYfTOWN
STATE
NAME (PRINT)
SIGNATURE.
DOH-98 (0312006)
(TH/S JPACE FOR STATE USE ONLY)
/, IJ ,/
..J>..... _)1_,", 7
~. ') J-' II ;./
/.:.:x ....."
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Heather Hoge Rivera
MIDDLE CURRENT SURNAME
~
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Garcia
(OPTIONAL.. SEE REVERSE) 1 05 74 4359
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN!'J VILLAGE
~~~CIFY Wappinqers Falls
D STREET ADDRESS 1 Wenliss Terrace; Apt 1 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
A)9 ;1'976
DAY
13. A. AGE 32
09
MONTH
YEAR
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS Unemployed
15. PLACE OF BIRTH Cortlandt, Ny
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A NAME Robert Rivera
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Blanca Velez
B. COUNTRY OF BIRTH Puerto Rico
18. NUMBER OF THIS MARRIAGE 1
19. 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
(31 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
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
o 0
o 0
o 0
o 0
eClar~: no legal impediment exists
USE CURRENT NAME
DATE 09/25/2008
by New York Domestic
MONTH
YEAR
11
24 2008
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 0 VILLAGE OF
SPECIFY
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE.