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COUNTY nlltr.hp.!';!';
CITYfTOWN W~ppinger
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~~~I~~~R 72
STATE OF NEW YORK
DEPARTMENT OF HEALTH
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~ . I h Ab
~1M'6R 0 n ~~NT SURNAME
L 0 SUPPLEMENTAL FILE -
FROM THE BRIDE
lemi~DD~g::lrip. r.::l\l~~~)l[~T SURNAME
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1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE A hem
(OPTIONAL. SEE REVERS'E)
D SOCIAL SECURITY NUMBER 1 ?R-R8-3214
12. RESIDENCE A, NY e, Dlltr.hp.c::c::
(STATE) (COUNTY)
C CHECK ONE 0 CITY V"l TOWN 0 VILLAGE
AND W .
SPECIFY ~pplnger
D STREET ADDRESS 10 Elizabeth Terrace ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13, A AGE 31 3B, DATE OF BIRTH 04 ,{J2 A q77
MONTH DAY YEAR
14, EMPLOYMENT
A USUAL OCCUPATION Ophth::llmir. Tp.r.hnir.i::ln
B. TYPE OF INDUSTRY OR BUSINESS Medical
15, PLACE OF BIRTH Rronx New Yark
(CITY, STATE / COUNTRY IF NOT USA)
16, FATHER
A, NAME I nllic:: Fmil r.::lv::llip.ri
'B, COUNTRY OF BIRTHU S A
17. MOTHER
A, MAIDEN NAME Donna Marie Olaizola
B. COUNTRY OF BIRTHU S A
1B. NUMBER OF THIS MARRIAGE 2
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 11 0- 7? -11 07
2 RESIDENCE A. NYsTATE) e, qc~6~ess
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND \^' '
SPECIFY ::lpplnop.r
D STREET ADDRESS 10 Elizabeth Terrace ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0(] NO
3 A. AGE 28 3B. DATE OF BIRTH MOQ.;z / 017 / yWS
4. EMPLOYMENT
A. USUAL OCCUPATION Installatiol1 I=oremen
B. TYPE OF INDUSTRY OR BUSINESS H\I Ar.
5, PLACE OF BIRTH I\AnI mt Kic::r.n Np.w Y nrk
(CITY, STATE I COUNTRY IF NOT USA)
6, FATHER
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A. NAME Robert Arthllr Aher'1, Ir
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A, MAIDEN NAME Inp.7 R::lrh~r::l M::lrkllm::l!,;
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 1
to
~
B
19, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 0 0
B, HOW DID LAST MARRIAGE END? (3) [!!' DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C, DATE LAST MARRIAGE ENDED? 00 / ?O (. ?OOR
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO
..
10, IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0 1ST 09/29/2006 Orange County, New York C!' 0
o 0 ~D 0 0
o 0 ~D 0 0
o 0 4TH 0 0
my knowledge and belief that the information I provided is tr e and that I de~gal impediment exists
22. SIGNATURE OF BRIDE Ii!:
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
n
o
o
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
C, DATE LAST MARRIAGE ENDED?
YEAR
MONTH DAY
D, ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, t
as to my right to enter into the mama
21. SIGNATURE OF GROOM ~ '
by New York Domestic
USE CURRENT NAME
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USEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New k 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
DATE
06/20/2008
,-;-..
{ SEAL }
'-v-I
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
OR/?0/?008
AM
01 :31 PM
06
21
2008
08
19 2008
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY O&<rc...€5
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED,
10 CIVIL
C, LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF
SPECIFY E3"A-) T
o VILLAGE OF
h 5 Wi"- i '- L.-
i 2.)) 3
ZIP
31, WITNESS TO CEREMONY fYI.
NAME (PRINT) -r(; tJ I ~ 0
SIGNATURE~ ~ ~