143
+
......
OW
o ~
c.ClUl
o
r-:
()
.... to-
me :>
W 0 c:(
"'> Q
get: u.-
::l W
~~~
- ~
~g
....0. ~
~O
W --_
lX!'O
Weo
~O
!fa::
ro
"-0
00
~.3: .
oC
[f0
~
l&c
tf ~.
::E
::l
Z
Q
Z
<
tii
W
a:
lii
Ul
CIl
W
II:
o
o
<
t
u
W
"-
Ul
w
tJ)
z
-w
o
~
+
H~w
tu~~ to-
II: II: - c:(
~~~ 0
::lOW
::E(!J5 u:
~:!!:CIl _
~~~ t:
tEOCll w
0....> 0
w~~
SiD'"
z3:!!:
1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST GregQQ'Edohn Ec~lMQ~ SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
COUNTYDlltchA~~
CITYrrOWNW~rrinOAr
~~~:~:1368 .
~~~I~~R143
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Linda P,m&ia Corte5c~~RNAME
-.J
11. A. FULL NAME
FIRST
"-
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. s~S~~.t,.~~~t~~~~~~)cklund
D. SOCIAL SECURITY NUMBER 09?-70-4188
12. RESIDENCE ACt BH a rtfn I"rl
. (STATE) \~
C. CHECK ONE 0 CITY.,lJ TOWN 0 VILLAGE
AND
SPECIFYA\lon
D. STREET ADDRES~R Avnnwnnei Rei I Apt 206 z,Ff)6001
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VILLAGE? 0 YES\l'\'J NO
13 A AGE::'l-! 3B. DATE OF BIRTH 00 ..1.6 ~..t.RF\
., ";l!, I I\1ONTH (,It DAY <r~'fMR
14. EMPLOYMENT
A. USUAL OCCUPATloNAct1lary
B. TYPE OF INDUSTRY OR BUSINESsH~rtfnreil if A
15. PLACE OF BIRT..enllnhkAAn~iA NAW Ynrk
(CITY,'llTATE I COUNTRY I~ NOT USA)
16. FATHER
A. NAMeP-atricio Cortes
'B. COUNTRY OF BIRTiChilA
17. MOTHER
A. MAIDEN NAME.limAn~ Rnj~~
B. COUNTRY OF BIFrnChilA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER 053-74-7235
2. RESIDENCE A.Ct.(STATE) B. H~rd
c. CHECK ONE 0 CITY.,.o TOWN 0 VILLAGE
AND
SPECIFY Ii \Ion
D. STREETADDRESs48 A\lOnwnorl Rd, Art ?ORzIP OR001
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VILLAGE? 0 YE9oC! NO
Mdt9H / ~~ / '!,.a.i~
3. A. AGE2d
4. EMPLOYMENT
3B. DATE OF BIRTH
A. USUAL OCCUPATION Consultant
B. TYPE OF INDUSTRY OR BUSINESS Modis COl"'slllting
5. PLACE OF BIRT~~I\l~~~~,c~~':~ IX$?.f~SAI
6. FATHER
A. NAME SHeven Albert Ecklund
B. COUNTRY OF BIRTH I I S A
7. MOTHER
A. MAIDEN NAME Helen Frances Paternoster
B. COUNTRY OF BIRTH I I S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE --_..- ._.._----- ..CIVIL.ANNULMENT
g
o
o
o
DEATH
o
DEATH.--
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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) (CITYICOUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.. - YEAR
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
o
o
o
o
o
o
1ST
2ND
3RD
o 0
o 0
o 0
o 0
I impediment exists
USE CURRENT NAME
USE CU
23. SUBSCRIBED AND SWORN TO/AFFI ED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of t authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York te. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the urpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME(PRIN1) .lnh~Mfl~~
"{ SEAL SIGNATURE ~ . . c. ~ DATE 11/0Q/?007
MAILING ADDRESS f! AM
'-v-I ?O Mieieilp.hl~h Rei, WFJnpinap.rs FFJlIs NY 1?590 02'.22 PM 11
STREET ... Cffi'R'OWN ' STATE ZIP
~~R~~RT~~J IO~O~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. AY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME ANO
PLACE INDICATED. 9 0 OTHER. SPECIFY
DATE 11/09/2007
TIME
MONTH
YEAR
MONTH
YEAR
10
2007
01
08 2008
CIVIL
28. PLACE WHERE MARRIAGE OC<(JRRFO .,
A. STATE NEW YORK B. COU~P~
C. LOCATION OF CEREMONY
(CHECK ONE AND y-€c:IFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY W ~;:~f".8 '
SIGNATURE ~
MAILING ADD
/1
STREET
30. WITNESS TO CEREMONY
NAME (PRIN1) Gr rv "'r c.he..('\ 1:. Sm:--\'h
SIGNATURE~ J:t~~ [ ~
OOH-98 (0312006)
NAME (PRIN1)
SIGNATURE~