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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST DaviQo~gene C~'.<~SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COUNTY nlltches!=:
CITYITOWN WeppinOAr
~~J:~c; 1368 .
~5~1:~~R 147
SUPPLEMENTAL FILE
FROM THE BRIDE
~ Q: L. I II . lil
. ,m~ ~ ynn - ~ ENT SURNAME
~
Lo
11. A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~"N~~~~t~~c~~s~Yevas
D. SOCIAL SECURITY NUMBER 1 A.? -7 A.-4A.FlA.
12. RESIDENCEA.NY B.Dlltf'h.:>ss
(STATE) 1tlMr;;'f'I'l
C. CHECK ONE 0 CITY oIlI TOWN 0 VILLAGE
AND IAI .
SPECIFY vvapp'"OE'r
D. STREETADDRESS.~01 r.hAI!=:A:=J r.:=JY ZIP1?590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES III NO
~NTH Aj'~AY {~
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 066-62-4011
2. RESIDENCE A. N'(STATE) B. qM~ess
C. CHECK ONE 0 CITY -IJ TOWN 0 VILLAGE
AND \AI .
SPECIFY .. appmg~r
D. STREET ADDRESS 301 Chel,>ee r.ay ZIP 1 ?~qO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES olJ NO
3. A. AGE30 3B. DATE OF BIRTH M~ / ~ / 1~8
4. EMPLOYMENT
A. USUAL OCCUPATION Registered Nyrse
B. TYPE OF INDUSTRY OR BUSINESS M~dical
5. PLACE OF BIRTH\:y~,\m.il~clU~~WN~t'l.~
6. FATHER
A. NAME Fr:mcisco Salas Cue'Jas
B. COUNTRY OF BIRTH Pu~rto Rico
7. MOTHER
A. MAIDEN NAME Mildr&d Fay& Coleman
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
.DIV0RCE~-----.~-~..CNIL-ANNlJbMENT .
DEATH
n
13. A. AGE25
14. EMPLOYMENT
A. USUAL OCCUPATION R~gist~r~d Nurse
B. TYPE OF INDUSTRY OR BUSINESS MArliC'::=J1
15. PLACE OF BIRTHHackE'nsacl< New IAr!=:AY
(CITY. STATE I COUNTRY IF NOT USI\l
16. FATHER
3B. DATE OF BIRTH
A. NAMEJam&G Edward Ulrich
. B. COUNTRY OF BIRTH I S A
17. MOTHER
A. MAIDEN NAME Donna Marie Corrpa1e
B. COUNTRY OF BIRTH J S A
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1
o
o
o
o
B. HOW DID LAST MARRIAGE END? (3) i!!l 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? MONTH06/ 011 / faP2 C. DATE LAST MARRIAGE ENDED? MONTH / DAY .f. YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? Iil'YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10. IF PR!:VIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLlLOWING 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) (CITYICOUNTY. STATEICOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 06/17/2002 Kingston, NAW Ynrk 0 i"l 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, aep'ose a to the best of my knowledge and belief that the information I provided Is true and that I declare that no legal impediment exists
as to my right to enter into state. ~ ~
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~ .
USE CURR USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME 1 ?/12/2007
SIGNATURE OF TOWN OR CITY CLERK ~ DATE - _n ------
This license authorizes the mjrriage in New York te of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~1.1 to perform mlrriage 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
~
{ SEAL }
'-v-'
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
AM
01 :27 PM 12
12
2007
02
09 2008
1dC1vIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY O~OWN OF 0 VILLAGE OF
SPECIFY~(I vJj-f' r
ZIP
31. WITNESS TO CEREMONY (
NAME (PRINT) ~f\'(\\C L~l\ ~
SIGNATURE~:Jxi (\ , t \ \ l \). ~