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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 Edgar ~tflel Reyes C~~~nME
,
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~CRT 1368 .
~~~I~~~R139
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
B. BIRTH NAME. IF DIFFERENT
11. A. FULL NAME FIRST np!':~~DI(E I ~n~ WrigntNT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT Nie\les
c. SURNAME AFTER MARRIAGE Reyes
(OPTIONAL, SEE REVERSt)
D. SOCIAL SECURITY NUMBER 094-7?-4548
12. RESIDENCE ANY B.[)lltCh",!,:!,:
(STATE) (COUNTI;
C. CHECK ONE 0 CITY o/lI TOWN 0 VILLAGE
AND P hk .
SPECIFY Ollg pppf:le
D. STREET ADDREss1 07 Fulton Ave.: Apt G2
C. SURNAME AFTER MARRIAGE
(OPTIONAL, SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. D('I'tr-hess
(STATE) ell1lm'Yj
C. CHECK ONE 0 CITY.cJ TOWN 0 VILLAGE
AND P hk .
SPECIFY 01 '0 PPp!':IP
o STREET ADDRESS 107 Fulton Ave; Apt G2 ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES o,tJ NO
MOQ~ / JA~ / wa
ZIP 12603
o YES~ NO
X:979
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE28 3B. DATE OF BIRTH n7 ~4
'MONTH DAY
3. A. AGE29
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION CllstOlT'er Ser\lice
B. TYPE OF INDUSTRY OR BUSINESS Tn J(~k P~rt!':
5. PLACE OF BIRTH ~~~~~T~g~~~~~lT '2s~minir.~n Repllhlir.
6. FATHER
~ A. NAME R~f~pl IIllio Reyp!,:
<C B. COUNTRY OF BIRTH Dominican Republic
7. MOTHER
A. MAIDEN NAME Milagros Guzman
B. COUNTRY OF BIRTH Dominican Republic
8. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATION nent~1 A!':!':i!':t~nt
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH Bronxville, NY
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMEnpnni!': Nipvp!':
'B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAME Aida Luz Cortes
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 3
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDEO BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT DEATH
1 0 0 2 0 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) !!1 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 02/ 18 / ?005 c. DATE LAST MARRIAGE ENDED? 10 / 22 / 2007
MONTH DAY YEAR MONTH DAY' - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? I!fYES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? i!'1 YES 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) (CITYICOUNTY, STATElCOUr-ITRY, IF NOT USA) SELF SPOUSE (MONTH, DAY. YEAR) (ClTYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 02/18/2005 Dajabon, Dominican 0 ~ 1ST 10/22/2007 Poughkeepsie. New York '6
2ND 0 0 2ND 03/05/2005 Poughkeepsie, New York tJ
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, dep.ose and say edge and belief that the information I prov ded i t
as to my right to enter into the ma
21. SIGNATURE OF GROOM~ .
DATE
This license authorizes the marriage in New rk State of the bride and groom named above by any person authorized by New York Domestic
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
{ } NAME (PRINT) Jo C. Ma e son
TIME MONTH YEAR MONTH DAY YEAR
SEAL SIGNATURE ~ .
'-v-I MA20GMigfJrJ AM 10 27 2007 12 25 2007
STREET 07:21 PM
I CERTIFY THAT I SOLEMNIZED 28. PLACE WHERE MARRIAGE OCCURRED
THE MARRIAGE OF THE PER, ~
SONS NAMED ABOVE ON THE 1r CIVIL NEW YORK '7"\ 1tJtc-s5
DATE AND AT THE TIME AND A. STATE B. cou~iJ l ' .
PLACE INDICATED.
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY 0; It TOWN OF 0 ~LAGE OF
SPECIFY (JJ (ttt?(J/ ~ G- t:::.~