065
+
o
0)
L{")w
N~
...-li;
>-
Z
f-~
z-
w CO
~l..L
w
en
z
w
0
::::i
+
Z' .
a::I:Z W
::)t::Q
ti:f- ....
a: ",;:5 c:t
I-ffiz
(/)..J::;; 0
::>QW
::;;Cl5 u::
f-Z(/) ~
z-
G~~ a:
ttocn w
Of->-
W~C5 0
~z"'
O~
z::;;!;
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
F~rnii\rD9a Rafa~1 ~~~\jlJRNAME
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVILANNtJLMEMT
1 0
B. HOW DID LAST MARRIAGE END? 13).el DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 07 / 11 / 1 ~R3 C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR MONTH DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? r!fYES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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
n7/11/1~R3 Rell County, Tx l!I' 0 1ST 0 0
o 2ND 0 0
o 3RD 0 0
o 4TH 0 0
e nd belief hat the information I provided is true and that I declare that no legal impediment exists
22.SIGNATUREOFBRIDE~ ~ (!A~~
USE CURRENT NAME
DATE 06/09/2008
USE CU
23. SUBSCRIBED AND SW IRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK.
This license authorizes the marriage in New Y 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
NAME (PRINT) C. Ma te son
TITLE (YlAfI..R IkGJZ of,Ft c6(L
c.lz..'7/Jcw'i-
I IJ.)'10
TATE ZIP
31. WITNESS TO CEREMONY
COUNTY DlltchE'SS
CITYfTOWN \A1C1rpinapr
~~~~:f: 1368
~~~~;~R 6 5
1. A. FUUL NAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 10",-",4-4?04
2. RESIDENCE A. N"(STATE) B. qg~.p)~ss
C. CHECK ONE 0 CITY 0 TOWN,lJ VILLAGE
~~~CIFY weprinopr~ F;:tll~
D. STREET ADDRESS iifl14 Princess Circle ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
M~ / ~9 / ~E~R45
3 A AGE63
4. EMPLOYMENT
A. USUAL OCCUPATION 811s Dri\/er
B. TYPE OF INDUSTRY OR BUSINESS Ch~rtererJ RI J!=;
5. PLACE OF BIRTH R;y;:tmnn PI Jertn Ricn
(CI ,STATE / COUNTRY IF NOT USA)
6. FATHER
A NAME Francisco Beltren r,omE'7
B. COUNTRY OF BIRTH PI Jertn Rico
38. DATE OF BIRTH
7. MOTHER
A. MAIDEN NAME npli::! M~ri~ Reltr~n
B. COUNTRY OF BIRTH PIIPrto Rico
8. NUMBER OF THIS MARRIAGE 2
DEATH
o
a:
w
III
::;;
::;)
z
o
Z
<(
0-
W
W
a:
0-
w
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, th
as to my right to enter into the
21. SIGNATURE OF GR
~
{ SEAL }
'-..t-'
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-9B (03/2006)
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Cpli::! l\JI;:tri::! Cnlnn
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Reltral1
(OPTIONAL - SEE REVER~
D SOCIAL SECURITY NUMBER 065-44-7748
12. RESIDENCE ANY B. nlltr.hp.~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN~ VILLAGE
~~~CIFYW~ppingers Falls
D STREET ADDRESs5614 Princess Circle ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 'oQ YES 0 NO
/,$~ A~ii?
DAY YEAR
13. A. AGE55
10
MONTH
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUALOCCUPATIONNllrse
B. TYPE OF INDUSTRY OR BUSINESS Nursing Home
15. PLACE OF BIRTH Manhattan New Y ork
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Gon7~lo Colon
'B COUNTRY OF BIRTH2uerto Rico
17. MOTHER
A. MAIDEN NAME Carmen Zayas
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
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
09:58AM 06
PM
10
2008
08
08 2008
1~VIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY hu7tue",""
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
wA pr IN 6 e.(L.-
SPECIFY
NAME (PRINT)
v
SIGNATURE~