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COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c~ 1368 '
~~~I;~~R 78
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Fn~~g~JR RR;:!I Rb~fR~~SURNAME
FIRST
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Adelaida Melendez
MIDDLE CURRENT SURNAME
1, A FULL NAME
11, A. FULL NAME
FIRST
0.
N
B. BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE Rivera
(OPTIONAL - SEE REVERSE), (OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 081-58-8579 D. SOCIAL SECURITY NUMBER 050-62-1431
2. RESIDENCE A. NY B. Dutchess 12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY) (STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE C. CHECK ONE 0 CITY [!if" TOWN 0 VILLAGE
~~~CIFY Poughkeepsie ~~~CIFY Poughkeepsie
D. STREET ADDRESS 12 Gale Drive ZIP 12603 D. STREET ADDRESS 12 Gale Drive ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r!'! NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES f1 NO
3. A. AGE 36 38. DATE OF BIRTH 08 / 16 / 1970 13. A. AGE 29 3B. DATE OF BIRTH 12 /26 /1977
MONTH DAY YEAR MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Field Service Engineer
B. TYPE OF INDUSTRY OR BUSINESS Semiconductor
5. PLACE OF BIRTH Brooklvn. NY
(CITY, STATE I COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Police Officer
B. TYPE OF INDUSTRY OR BUSINESS City Of Beacon
15. PLACE OF BIRTH Beacon, NY
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Ruben Melendez
'B. COUNTRY OF BIRTH Puerto Rico
17. MOTHER
A. MAIDEN NAME Nilda E. Morales
B. COUNTRY OF BIRTH Puerto .Rico
18. NUMBER OF THIS MARRIAGE 2
6. FATHER
A. NAME Enrique Rivera
B. COUNTRY OF BIRTH Puerto Rico
7. MOTHER
A. MAIDEN NAME OIQa Real
B. COUNTRY OF BIRTH Puerto Rico
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
100
B. HOW DID LAST MARRIAGE END? (3) cfDIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) c1DIVORCE (3) 0 ANNULMENT 12LO DEATH
c. DATE LAST MARRIAGE ENDED? 12/ 19 / 2006 C. DATE LAST MARRIAGE ENDED? 06 / 12 / 2uu2
MONTH", DAY YEAR MClNTlV DAY, '. ~ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ITYES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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, STATE/COUNTRY, IF NOT USAk SELF SPOUSE (MONTH, DAY, YEAI] (CITYICOUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 12/19/2006 Poughkeepsie, New Yor 0 c1 1ST 06/12/200~ Poughkeepsie, New York D" 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, dep.ose and sa 0 e best of my knowledge and belief that the information I provided is true and that I declare t at legal impediment exists
as to my right to enter into the lage e. ..
I
21. SIGNATURE OF GROOM ~ .....
DEATH
o
DEATH
22. SIGNATURE OF BRIDE
US
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New 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.
r-^-.. 24. TOWN OR CITYJC ERKC M 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) n. asterson
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~
MAI~ ~ 07 31 2007 09 28 2007
'-..t--I STREET STATE
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
YEAR
c ~)
28. PLACE WHERE MARRIAGE OCCURRED (
A. STATE NEW YORK B. COUNTY'D, .\-c-~ "> )
C. LOCATION OF CEREMONY
(CHECK ONE AND?ECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY~\,~~
NAME (PRINT)
SIGNATURE~