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COUNTY Dutchess
CITYfTOWN \Mappinger
DISTRICT ..
NUMBER~ aeg
REGISTE
NUMBER 1 '11
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
J ot1m,L~lIi ot Y a~ENT SURNAME
SIAII: r!L.t: NUMIlEH
(THIS SPACE FOR STA TE USE ONL Y)
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Mi.~ra Cotto CURRENT SURNAME
1 . A FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). I F DIFFERENT
C. SYS~~~rfA~~~~t~wc~~~ambo
D SOCIAL SECURITY NUMBER ~R?-4:i-RRfi7
12. RESIDENCE ANY(STATE) BDI (~~Ss
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND \^' .
SPECIFY applnopr
D. STREET ADDRESD:i FrJgAhil1 Road z,P12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES~ NO
13. A AGE36 3B. DATE OF BIRTH -~TH /jqAV ,.{~l.~
14. EMPLOYMENT
A. USUAL OCCUPATIONDental Assistant
B. TYPE OF INDUSTRY OR BUSINESS nAnt::J1
15. PLACE OF BIRTHPllPrtn Rir.n
(CITY, STATE / COUNTRY IF NOT USA)
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 076 58 63'12
2. RESIDENCE A. NY. B. n. .~"hPSS
(STATE) '"1~""
C. CHECK ONE 0 CITY.jJ TOWN 0 VILLAGE
AND
SPECIFY Wappinger
D. STREET ADDRESS 23 Edgehill Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPDRA TED VILLAGE? 0 YESo,l] NO
McO~ / 62 /~~JO
3. A AGE38
4. EMPLOYMENT
3B. DATE OF BIRTH
A USUAL OCCUPATION Yard Supervisor
B. TYPE OF INDUSTRY OR BUSINESS Paving
5. PLACE OF BIRTH ~~ ~
, IE / UNTRV IF NOT USA)
6. FATHER
16. FATHER
A. NAME Nelson Yambo
B. COUNTRY OF BIRTH U 53 A
7. MOTHER
A MAIDEN NAME Elizabeth Palermo
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
,A. NAMEAngel LLlis Cotto
B. COUNTRY OF BIRTt-P-IIArtn R ir.n
17. MOTHER
A. MAIDEN NAME R(;Imnnit::l r.::lm::Jr.hn
B. COUNTRY OF BIRTt-P-IIArtn Rir.n
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
n
DEATH
o
o
o
(2) 0 DEATH
o
o
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.' YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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/COUNTRV, IF NOT USA) SELF SPOUSE
C. DATE LAST MARRIAGE ENDED?
MONTH DA V 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/COUNTRV, IF NOT USA) SELF SPOUSE
W
en
z
W
(,)
::;
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 k owledge and belief that the information I provided i:.;7jS true andrl. hat I declare that n. 0 le~al impedi ~. lexists
as to my right to enter into the ,JJ:larn ge state. . I ') II -"
,. '4 fir. . ^:>
21. SIGNATURE OF GROOM~ ,~(V ).'\ 22. SIGNATURE OF BRIDE~ " V \...-.
L US C)IR T NAME ( SE CURRENT NAME
23. SUBSCRIBED AND SWORN TOiAFF;lRMED BEFORE E '-.- 09/22/2008
SIGNATURE OF TOWN OR CITY crERK ~ ,- DATE ----------
This license authorizes the marriage in New Y r)< State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perlorm marriage ceremonies w hin 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
~
{ SEAL}
'-r-'
NAME (PRINT)
MONTH
YEAR
YEAR
TIME
MONTH
1 0:44AM
PM
09
23
2008
11
21 2008
I STATE
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 0 RELIGIOUS
;1: 00 AM I , ~Ef 9 0 OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY u'JA(H}i N~(l.__
STR
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
1~IVIL
A. STATE NEW YORK B. COUNTY
b l/7CJ{.e$5
29. OFFICIANT
NAME (PRINT)
TITLE """CJW(} C-/.-e~
DATE~
N .;t5
NAME (PRINT)
SIGNATURE~