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COUNTY nlJtchRSS
CITYfTOWN Wappinger
~~~:~CRT 1 368
~~~I;;~R 79
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.IOSE'p@D&ph~E'1 G~b~~[jfj,raRNAME
r
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
7ahira I i7 (.;nn7alR7
MIDDLE CURRENT SURNAME
-1
1 . A. FUU NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE GllPrrirln
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 064-70-0141
12. RESIDENCE A NY B. nlltchpss
(STATE) (COUNTY)
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 11 H White Gate Road
B. BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 06?-7?-4!=i88
2. RESIDENCE A. NYsTATE) B. q6!t~.ptC::C::
C. CHECK ONE 0 CITY olJ TOWN 0 VILLAGE
AND W .
SPECIFY arrlngpr
o STREET ADDRESS 11 H White Gate Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES otJ NO
3. A. AGE 22 38 DATE OF BIRTH Mo~1 / dA9 / JE~R86
4. EMPLOYMENT
A USUAL OCCUPATION Prodllr.pr/FnOinppr
B. TYPE OF INDUSTRY OR BUSINESS M1Jsic
5. PLACE OF BIRTH Rrnn)( Npw Y nrk
(CITY, STAtE / COUNTRY IF NOT USA)
ZIP 12590
o YES~ NO
A'~8fi
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIULAGE?
13. A. AGE7? 3B. DATE OF BIRTH 07 A')4
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS DCC
15. PLACE OF BIRTH Brooklyn New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME I uis A Gnnzalez
'B COUNTRY OF BIRTHPuerto Rico
6. FATHER
A. NAME 'ClimE' (.;IIPrrirln
B. COUNTRY OF BIRTH LJ S A
7. MOTHER
A. MAIDEN NAME Fsther Matta
B. COUNTRY OF BIRTH l J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES.WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
17. MOTHER
A MAIDEN NAME Maribel Cruz
B. COUNTRY OF BIRTHPuerto 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
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / ~
MONTH DAY YEAR
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
(3) 0 ANNULMENT
/ /
DAY
oNO
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES
YEAR
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
a:
w
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1ST 0 0 1ST
2ND 0 0 2ND
~ 0 0 ~
4TH 0 0 4TH
I duly swear/affirm, de~ose and say, that to the best of my knowled e and belief that the information I provided is true and that
as to my right to enter into the amage tate. -
21. SIGNATURE OF GROOM.
W
U)
Z
W
o
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23. SUBSCRIBED AND SWORN TOI FIRMED
SIGNATURE OF TOWN OR CITY ERK ~
This license authorizes the marriage in New rk State of the bride and groom named above by any person authorized
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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
C.M
MONTH
YEAR
by New York Domestic
~
{ SEAL }
'-.t-I
NAME (PRINT)
YEAR
TIME
MONTH
DATE 07/02/2008
ers Falls NY 12590
WN STATE ZIP
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
AM
06:31 PM 07
03
2008
08
31 2008
28. PLACE WHERE MARRIAGE OCCURRE
A. STATE NEW YORK B. COUNTY I
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
l'f.-CIVIL
Idt:tSS
o CITY OF ~ TOWN OF ~VIL~~F
SPECIFY CY1PfJ(!~ r1j-(t~c:.
~aF
.0
ZIP
" w""", "ljJ;'Mom
"'" 'eR'"iL, !9~d UZ:
SIGNATURE'" '/
SIGNATURE~
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