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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFADAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST RobertlUVjlliam Jor~nNrL5RNAME
1ST
2ND
3RD
4TH
I duly swear/affirm, depose a
as to my right to enter into th
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFO.RE.
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York 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
COUNTY Dlltchess
CITYiTOWN \N8rpinOF!r
~~~:~CRT 1368
~~~~;~R 54
1 . A. FULL NAME
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 060-74-4263
2 RESIDENCE A. NYsTATE) B. q\db~liSS
C CHECK ONE 0 CITY JlJ TOWN 0 VILLAGE
AND .
SPECIFY \^'applnger
D. STREET ADDRESS ~ 1 R Sr.::lrhnrnlloh I ::lnp. ZIP 1 ?!1QO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES.tJ NO
M01+J / Q~ / 1~84
3. A. AGE 23
4. EMPLOYMENT
3B. DATE OF BIRTH
....
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c
it
A. USUAL OCCUPATION OR T lichnician
B. TYPE OF INDUSTRY OR BUSINESS Medical
5 PLACE OF BIRTH ~~IJr~;~i!b~l1J';l$';~^~oYu~Lk
6. FATHER
A. NAME Robert William Jordan
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Aida Freyre
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) 0 DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C, DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
'0. 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
o
o
~
{ SEAL }
'-v-'
NAME (PRINT)
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-98 (03/2006)
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
I 'f \/ I t'
eWher a en mmENT SURNAME
11. A FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SY~~*~~i~~~rl~wo~~sJprd a n
D SOCIAL SECURITY NUMBER OQO-nn-404?
12 RESIDENCE A.NXSTATE) B, Dt!tg~ss
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY ::lrrmop.r
o STREET ADDREss31 B Scarborough Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
'3 A. AGE 25 38 DATE OF BIRTH Q~TH -1 ~AY .1 ~J1f
14. EMPLOYMENT
A USUAL OCCUPATION Medical Assistant
B. TYPE OF INDUSTRY OR BUSINESS Mp.rlir.::lI
15. PLACE OF BIRTH Ynnkp.r!':. Np.w Ynrk
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
.A NAME Gregory \/alentin
B. COUNTRY OF BIRTHI I S A
17. MOTHER
A. MAIDEN NAME Np.lly M::lO::llly Hirl::llon
B. COUNTRY OF BIRTHII S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
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
1ST
2ND
3RD
o
o
o
DATE
by New York Domestic
TIME
YEAR
MONTH
YEAR
MONTH
11 :49~~ 05
2008
07
26 2008
28
ZIP
1~L
2B. PLACE WHERE MARRIAGE OCCUR~ \
A. STATE NEW YORK B COUNTY)' l J (\OV t;~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN.oF 0 VILLAGE OF
""'"'' \Vq ~ I IV ~j S