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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
M~M~o Diaz, J&ENT SURNAME
COUNTY Dutchp.~~
CITYfTOWN Wappinger
~~~:f;i 1 ~flR '
~5~~~~R 145
"1. A. FULL NAME
FIRST
..
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. ~~ATE)
C. CHECK ONE 0 CITY [;lo' TOWN 0
~~~CIFY Wappinger
D. STREET ADDRESS 1 I nno r.n1 Jrt ZIP 1 ?5QO
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Ui'" NO
MON~ / D~6 / Yd972
116-56-5386
B. B~8SS
VILLAGE
3. A. AGE 35
4. EMPLOYMENT
3B. DATE OF BiRTH
A. USUAL OCCUPATION Financial .6d\lisor
B. TYPE OF INDUSTRY OR BUSINESS C""::I~A InvA~tmAnt~
5. PLACE OF BIRTH M::Inh::ltt::ln NAW V nrlc
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Julio Ramon Almonte Dia~
B. COUNTRY OF BIRTH Dominican Rep'lb1ic
7. MOTHER
A. MAIDEN NAME Sixta Fernandez
B. COUNTRY OF BIRTH Dominican Republic
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBEROF_PBEVIOUS.MABBI.AGES WHICtt ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
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) (CITYICOUNTY. STATElCOUNTRY. IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
Lo
SUPPLEMENTAL FILE
FROM THE BRIDE
ijw.~ilda Ort89iRENTSURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Diaz
(OPTIONAL - SEE REVERSE)
D. SOCIALSECURITYNUMBER nR7-R4-g44~
12. RESIDENCE A. N~ATE) B. qcM~~e5is
c. CHECK ONE 0 CITY []I TOWN 0 VILLAGE
AND W .
SPECIFY ~pr,nger
D. STREET ADDRESS 1 I nng r.n1 Jrt ZIP 1 ?fiQO
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Ui'" NO
13. A. AGE 26 3B. DATE OF BIRTH ~~H / ~Iy /j~~9
14. EMPLOYMENT
A. USUAL OCCUPATION Banker
B. TYPE OF INDUSTRY OR BUSINESS r.h::l~A InvA~tmp.nt~
15. PLACE OF BIRTH M::Inh::ltt::ln Np.w Ynrk
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
. A. NAME Martin Ortega
B. COUNTRY OF BIRTH Pllp.rtn Rir.n
17. MOTHER
A. MAIDEN NAME Marilyn Segarr::l
B. COUNTRY OF BIRTH I I S A
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) AUVE? 0 YES 0 NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATIOI
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
IE:
W
III
2
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o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
nowledge and belief that the Information I provided is t
,
o 0
o 0
o 0
o 0
r that no legal impediment exists
1ST
2ND
3RD
4TH
I duly swear/affirm. aep'ose and say, th
as to my right to enter into the mama
21. SIGNATURE OF GROOM~
USEC
23. ~~~~~~Do~N.fo~OJl: J~:;r:f~ ~BEFORE ME DATE 11/1 Q/?007
This license authorizes the m 'age In New York State of authorized by New York Domestic
Relations Law ~11 to perform 'age ceremonies within New York te. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If cheCked, this license is to be used onl se of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL }
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NAME (PRINT)
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NAME (PRINT)
SIGNATURE~
DOH-9S (0312006\
.
25. 6. SOLEMNIZATION PERIOD
ENDS AT MIONIGHT ON:
TIME
MONTH
YEAR
MONTH
DAY
YEAF
11
20
2007
01
18 2008
28. PLACE WHERE MARRIAGE OCC~
A. STATE NEW YORK B. COU~~,"
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./'
o CITY OF 0 TOWN OF cYVlLLAGE c;.- Ii
PECIFY W/It(JOt7I4,,~ ~
ZIP
31. WITNESS TO CERE~ONY~
NAME (PRINT). E(.I ~~ ~ \.L) --
SIGNATURE~ ~....... l,1..~ '-