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COUNTY nlltr.he~~
CITYrrOWN W::Jppinoer
~~~:~; 1 ~nR .
~~~~~~R 7 ~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ri~bHo Luis Or~~SURNAME
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
I
Lo
SUPPLEMENTAL FILE
FROM THE BRIDE
Mich~Aht Ann P()m8ritr~
I LE UR SURNAME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE nrozco
(OPTIONAL. SEE REVERSEr:
D. SOCIAL SECURITY NUMBER 262-95-1229
12. RESIDENCE A. NY B. n"tr.hp.~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY Iii!' TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 1668 Route 9. Apt. 7 E
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER nnR-nR-4~~ 1 '
2. RESIDENCE A. N'XTATEI B. ~~U~E'''S
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY ::Jppmger
D STREET ADDRESS 1668 Route 9 Apt. 7 E
ZIP 12590
DYES~NO
;tGRO
YEAR
ZIP 12590
YES ~ NO
/ 1 ~R 1
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
3. A. AGE 25 3B. DATE OF BIRTH 11 / n~
MONTH DAY
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE ?7 3B. DATE OF BIRTH O~ Aln
MONTH DAY
~
:;
ct
C
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jIJ.
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4. EMPLOYMENT
A. USUAL OCCUPATION Ret::Jil M::Jn::Joer
B. TYPE OF INDUSTRY OR BUSINESS Four Maples Fish
5. PLACE OF BIRTH Brooklvnr New York
(CITY, STATEtJ COUNTRY IF NOT USAI
6. FATHER
A. NAME ,Jn~e I I Ji~ Orn7r.n
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Miguelina Donawald
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
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
14. EMPLOYMENT
A. USUAL OCCUPATION Certified Dental Assistant
B. TYPE OF INDUSTRY OR BUSINESS Endodontic Assoc.
15. PLACE OF BIRTH Fort Myers Florida
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Mich::Jel Peter Pnmaricn
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Donna Marie Gliamas
B. COUNTRY OF BIRTH USA
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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? DYES D NO
10. 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
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true a
as to my right to enter into the marriage state.
,
21. SIGNATURE OF GROOM ~ 2. SIGNAT E OF BRIDE ~
o 0
o 0
o 0
o 0
~ that I declare t~1 impedime~t exists
./~
USE CURRENT NAME
DATE
07/23/2007
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USE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York 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 St e. 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) Joh C. Masters n
{SEAL SIGNATURE ~ DATE 07/23/2007 TIME MONTH YEAR MONTH
'- -.J MAI~ItfiPc!fffi~b Rd, Wa pinger Falls, NY 12590 AM 07 24 2007 09 21 2007
--v- 01 :12PM
STREET CITYrrOWN STATE ZIP
~~~R~~Ri~~~ 'o~O~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY /"
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 IQo1:IVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~lA.lGijt&8
C. LOCATION OF CEREMONY
(CHECK ONE AN~ECIFY)
o CITY OF . rJYTOWN OF 0 VILLAGE OF
SPECIFY ~ i"',~u....
NAME (PRINT)
SIGNATURE~