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COUNTY Dutchess
CITYfTOWN WappinQer
~~~:~; 1368
~~~I:~~R 7
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Her.torMI~D~js Hernanc~~~ ~~NAME
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Winifred C. Davillier
MIDDLE CURRENT SURNAME
~
1. A. FUU NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT Coleman
C. SURNAME AFTER MARRIAGE Hernandez
(OPTIONAL - SEE REVERSE) 930
D. SOCIAL SECURITY NUMBER 435-04- 2
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 222 Town View Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r!"f NO
05 . /19 /'\ 972
MONTH DAY YEAR
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)521 29 9334 .
D. SOCIAL SECURITY NUMBER __ - __ - _
2. RESIDENCE A NY B. Dlltchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY olJ TOWN 0 VILLAGE
~~~CIFY Fishkill
D STREET ADDRESS 222 Town View Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
nq /?1 /1973
MONTH DAY YEAR
13. A. AGE 35
3. A. AGE 341
3B. DATE OF BIRTH
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Tn Jck Driver
8. TYPE OF INDUSTRY OR BUSINESS Transportation
5. PLACE OF BIRTH Blvtheville, Arkansas
(City. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME HF!r.tnr I IIi!=: Hern~nrle7 Sr
8. COUNTRY OF BIRTH Puerto Rico
7. MOTHER
A. MAIDEN NAME Frances Campos
B. COUNTRY OF BIRTH L J S A
8. NUMBER OF THIS MARRIAGE 1
14. EMPLOYMENT
A. USUAL OCCUPATION Registered Nurse
8. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH New Orleans. LA
(CITY . STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Unknown
'B. COUNTRY OF BIRTH Unknown
17. MOTHER
A. MAIDEN NAME Ida Frances Coleman
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 4
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
3 0
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) ~DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
/ / C. DATE LAST MARRIAGE ENDED? 11 / 07 / 2005
MONTH DAY YEAR MONTH DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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 11/28/1994 Jefferson Parish, 0 r!!
o 0 2ND 01/15/2004 St. Tammany Parish. 0 r:f
o 0 3RD 11/07/2005 Jefferson Parish. d 0
o 0 4TH 0 0
my knowledge and belief that the Information I provided is ~Ulrnd thlit I d~clare that no legal impediment ,exists
22 SIGNATUREOFBRIDE~W~ C _ l1a{)~
~URRENT~
DATE 01 /30/2008
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n n
DEATH
n
DEATH
o
C. DATE LAST MARRIAGE ENDED?
21. SIGNATURE OF GROOM
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23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE M
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
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
by New York Domestic
,-I'-..
{ SEAL}
'-v-I
NAME (PRINT)
MONTH
DAY
YEAR
MONTH
DAY
YEAR
TIME
AM
03:46PM
03
30 2008
2008
01
31
1~IVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY D )"i7'_~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF K TOWN OF 0 VILLAGE OF
SPECIFY r;J/tPP,l J ~-K.'
~:i:z w
i=~2
~ ~ ~ ~ 29 OFFICIANT
3 ~ ~ 0 NAME (PRINT)
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w~<3 0
~aJl/)
~~~
SIGNATURE~
DOH-98 (0312006)