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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~c; 1368
~~~I~;~R 1 3
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
M9~ II Ian I-ll'>r~a~~
DLE RNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
M(;lrQlI~6lttl'> Ann ~g3AmYsuRNAME
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Hernandez
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 093-58-8540
12. RESIDENCE A. NYsTATE) B ~~~J'~r~~
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
AND P hk .
SPECIFY nllg P.P.p!=:lP.
D. STREET ADDRESS 5 Grant Street ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? M YES 0 NO
13. A. AGE 32 3B. DATE OF BIRTH Po;tH . /~~Y /\~6
14. EMPLOYMENT
A. USUAL OCCUPATION Im/l'>ntnry Sper.i~list
B. TYPE OF INDUSTRY OR BUSINESS Rp.tail
15. PLACE OF BIRTH ~~,I ~g~~~~~~ii NO~X,)
16. FATHER
,A. NAME Ronald Patrick Sh~rpe
B. COUNTRY OF BIRTH l J ~ A
17. MOTHER
A. MAIDEN NAME K~thlp.p.n Ann Flmp.nrlnrf
B. COUNTRY OF BIRTH II ~ A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. N V
(STATE)
C. CHECK ONE eJ CITY 0 TOWN 0
AND P hk .
SPECIFY nil!) P.P.p~lP.
D. STREET ADDRESS 5 Grant Street ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
MO~ / ~ / Yt~70
B 9c~~e9s
VILLAGE
3. A. AGE 37
4. EMPLOYMENT
A. USUAL OCCUPATION Constp Iction
B. TYPE OF INDUSTRY OR BUSINESS Rllillrlin!)
5. PLACE OF BIRTH O(;lY~r.(;l Mp.Yir.n
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
3B. DATE OF BIRTH
A. NAME Mlilrcelino luan Felipe
B. COUNTRY OF BIRTH Mp.Yir.n
7. MOTHER
A. MAIDEN NAME r.~ndl'>l(;lri~ Hp.rn~nrlp.7 Pp.rp.7
B. COUNTRY OF BIRTH MeYico
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
.DIVORCE .CI\IlLANNULMENT
DEATH
DEATH
o
(2) 0 DEATH
o
o
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
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
10. 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
4TH
I duly swear/affirm, depose and say, that to th
as to my right to enter into the mama
21. SIGNATURE OF GRooM'-
o
o
o
o
o
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23. SUBSCRIBED AND SWORN TO/AFFIRME
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 !l11 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) IO~P-:.C...l\~WSOn-
SEAL SIGNATURE~ "'Le. ~ DATE n3/05/200
MAILING ADDRESS . . AM
'-v-I STR~ Middlel5'1sh Rd, '^'ap~r~ F9I1ssT~~ 1 ?5QQp 12:04.PM 03
I CERTIFY THAT I SOLEMNIZED 28. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ~
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
05
04 2008
DATE
by New York Domestic
YEAR
MONTH
YEAR
TIME
MONTH
06
2008
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. co~c;h:$S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 lOWN OF ~GE OF
SPECIFY~A17PiM>1M ~.
ZIP
WITNESS TO CEREMONY
NAME (PRINT) , ) 51:1 () Q:a
~
'& b tV c:.rl G "t.
~th\l E:
SIGNATURE~