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STATE OF NEW YORK
DEPARTMENT OF HEALTH
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE" ..h GIVIL.-ANNlJI,MENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ 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? 04/ 01 / 2004 C, DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR MONTH DAY YEAR
D, ARE ANY FORMER SPOUSE(S) ALIVE? &YES 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
04/01/2004 Orange County. NY 1'1 0 1ST 0 0
o 0 2ND 0 0
o 0 ~D 0 0
o 4TH 0 0
nowledge and belief hat the information I provided is true and that I declare that no legal impediment exists
22, SIGNATURE OF BRIDE~ {\.l1t1AJr/t k.A ~
USE CURRENT NAME
US
23. SUBSCRIBED AND SWORN TO/AFFIRMED 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 pertorm 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. M
DATE 05/14/2008
ers Falls NY 12590
WN STATE ZIP
27, TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
COUNTY Dutchess
CITYiTOWN Wappinger
~~~:~c: 1 368
~~~I;~~R49
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Daniel James Schubert
MIDDLE CURRENT SURNAME
1. A. FULL NAME
FIRST
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 0 6 19 8
D SOCIAL SECURITY NUMBER 07 -6 - 4
2 RESIDENCE A, NY B, Dutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY..o TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 11 G Millholland Dr ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"6 NO
10 /10 /1974
MONTH DAY YEAR
3, A, AGE ::\::\
3B, DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Self-Employed
B TYPE OF INDUSTRY OR BUSINESS Industrial Distribution
5, PLACE OF BIRTH Mineola, NY
(CITY , STATE / COUNTRY IF NOT USA)
6, FATHER
A NAME Ralph W Schubert
B. COUNTRY OF BIRTH USA
7, MOTHER
A. MAIDEN NAME Nancy E. Cocuzzo
B, COUNTRY OF BIRTH USA
8, NUMBER OF THIS MARRIAGE 2
DEATH
o
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say,
as to my right to enter into the mar
21, SIGNATURE OF GROOM~
w
en
z
w
o
::::i
~
{ SEAL }
'-v-'
29, OFFICIANT
NAME (PRINT)
DATE
AI
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Christina Maria Soto
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE Schubert
(OPTIONAL - SEE REVERSE)089_68_1739
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 11 G Millholland Dr
ZIP 12524
DYES '6 NO
;f'977
YEAR
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13, A, AGE 30 3B, DATE OF BIRTH 06 ~4
MONTH DAY
14, EMPLOYMENT
A USUAL OCCUPATION Teacher
B, TYPE OF INDUSTRY OR BUSINESS Carmel CSD
15, PLACE OF BIRTH Carmel, NY
(CITY, STATE / COUNTRY IF NOT USA)
16, FATHER
A NAME Victor Alfonso Soto
'B. COUNTRY OF BIRTHPeru
17, MOTHER
A. MAIDEN NAME Linda Gallo
B, COUNTRY OF BIRTHU S A
18, NUMBER OF THIS MARRIAGE 1
19, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DATE
05/14/2008
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
AM
04:45PM
2008
07
13 2008
05
15
CIVIL
28, PLACE WHERE MARRIAGE OCCURRE~
A STATE NEW YORK B, COUNTYr~
C, LOCATION OF CEREMONY
(CHECK ONE ANDYPECIFY)
o CITY OF ff'TOWN OF 0 VILLAGE OF ~
SPECIFYf~~ ( . 'i-
(ef?
ZIP
31, WITNESS ~R"
NAME (PRINT) J ~
SIGNATURE~