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COUNTY Dutchess
CITYITOWN Wappinger
~~~:f: 1368 '
~~~I:~R 113
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
r.::l~!g~ Mir.hAII ~tftMfN.rC;SURNAME
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kimb~~~ Anne Bo~~n~~URNAME
..J
1 , A, FULL NAME
11, A. FULL NAME
FIRST
FIRST
0.
f:;j
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Bonanno - Reyes
(OPTIONAL - SEE REVERSE) 118 58 6307
D. SOCiAl SECURITY NUMBER --
12. RESIDENCE A. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VilLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 82 Townview Drive ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
/17 /1975
DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 581-71-7090 '
2. RESIDENCE A. NFW YORK B. DutchASS
(STATE) (COUNTY)
C. CHECK ONE 0 CITY lS!I' TOWN 0 VilLAGE
~~~CIFY Fishkill
D. STREET ADDRESS 82 Townview Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
3. A. AGE ?7 3B. DATE OF BiRTH 01 / 03 / 1980
MONTH DAY YEAR
3B. DATE OF BIRTH
05
MONTH
13. A. AGE 32
4. EMPLOYMENT
A. USUAL OCCUPATION Truck Driver
B. TYPE OF INDUSTRY OR BUSINESS Mountain Ser. Dist.
5. PLACE OF BIRTH Bavamon. Puerto Rico
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Jorge Enrique Reyes
B. COUNTRY OF BIRTH Puerto Rico
7. MOTHER
A. MAIDEN NAME Ana Iris Miderez
B. COUNTRY OF BIRTH Puerto Rico
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o "'lr
14. EMPLOYMENT
A. USUAL OCCUPATION Clinical Social Worker
B. TYPE OF INDUSTRY OR BUSINESS Mental Health Assoc.
15. PLACE OF BIRTH Yonkers, New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Unknown
'B. COUNTRY OF BIRTH Unknown
17. MOTHER
A. MAIDEN NAME Linda Bonanno
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
"0 0
DE~H
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
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, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT
/ /
1ST
2ND
3RD
4TH
I duly swear/affirm. depose and
as to my right to enter into the
21. SIGNATURE OF GROOM"
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
my knowledge and belief that the information I provided is tN
o 0
o 0
o 0
o 0
al impediment exists
rx~
AME 09/10/2007
DATE
authorized by New York Domestic
TURE OF BRIDE ~
for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
YEAR
MONTH YEAR
2007
11 09 2007
TREET CI IT N
30. WITNESS TO CEREMONY B
NAME(PRINl)_~~~J o~
SIGNATURE~ ~
OOH-98 (0312006)
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYj)v/d;~$5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN.oF 0 VILLAGE OF
SPECIFY WlffJ/IAl6EK:.
IIrLU~ 80 hi~
( ( {.
c0.. ce