071
+
o
0>
LO~
N<
I-
~rJ)
>-
Z
u. .
o
~
(,)
iL.
~
w
(,)
w
a:
w
i
UJ
UJ
w
a:
o
~
~
u
w
n.
UJ
w
-C/)
z
-w
(.)
-::i
H~w
~;~ ~
!!lG~ (.)
2:ClO u:
!Z;!!;UJ -
~~~ ~
itCiUJ w
~~~ (.)
~~~
o~z
Z:J_
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~ 1368 '
~~~I~J~R 71
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
11, A. FULL NAME
FIRST
Soni::! Isis Roj::!s
MIDDLE CURRENT SURNAME
n.
N
1. A. FULL NAME FIRST r.hri~tn~~~r Anthon~u~:i$ftgRr;nME
B. BIRTH NAME, IF DIFFERENT L E'E'
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 050 68 7358
D. SOCIAL SECURITY NUMBER --- - -- - ----
2. RESIDENCEA. NY B. nlltr.hA~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY appmger
D. STREET ADDRESS 15 Sorina Hill Court ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 41 3B. DATE OF BIRlTH 04 /?~ / 1966
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Production Manager
B. TYPE OF INDUSTRY OR BUSINESS Coco Bon Bons. Inc.
15. PLACE OF BIRTH Manhattan. New York
(CITY, STATE J COUNTRY IF NOT USA)
16. FATHER
A. NAME Jeremias A. Rojas
'B. COUNTRY OF BIRTH Dominican Republic
17. MOTHER
A. MAIDEN NAME Sonia Maria Reynoso
B. COUNTRY OF BIRlTH Dominican Republic
16. NUMBER OF THIS MARRIAGE 2
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE I AAtnm
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 152-80-8837
12. RESIDENCEA. N .1 B. Hudson
(STATE) (COUNTY)
C. CHECK ONE 0 CITY!i1'l TOWN 0 VILLAGE
~~~CIFY Weehawken
D. STREET ADDRESS 1 01 Hauxhurst Avenue
ZIP 07086
DYES tJ NO
~73
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE ~4 3B. DATE OF BIRTH 03 ..111
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Programmer
B. TYPE OF INDUSTRY OR BUSINESS Vision Data
5. PLACE OF BIRTH Kingston. Jamaica
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Edgar Aloysius Lee
B. COUNTRY OF BIRTH Jamaica
7. MOTHER
A. MAIDEN NAME Patricia Veronica Buckland
B. COUNTRY OF BIRlTH Jamaica
B. NUMBER OF THIS MARF,lIAGE 3
9 PREVIOUS MARRIAGES - 19. PREVIOUS MARRIAGES
. A. NUMBER OF PREVIOUS MARRIAGES wi'ilCH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT DEATH
2 0 0 1 0 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) d'DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 01 / 07 / 2007 C. DATE LAST MARRIAGE ENDED? 12 / 06 / 2000
MONTIV DAY YEAR MONTIU DAY' '.- YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? UYES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? C1 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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
08/09/2000 White Plains, NY r:f 0 1ST 12/06/2000 Bloomfield, N J 0 ~
01/07/2007 Rockland County, NY. ref 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
- 22.SIG TUREOFBRIDE~ ~-': ZA...~-~'
~ lJs'E"C(jRRENT NAME ~
DATE 07/19/2007
e bride and groom named above by any person authorized by New York Domestic
tate. THIS LICENSE VALID IN NEW YORK STATE ONLY.
only for the purpose of a second or subsequent ceremony,
25. A. SOLEMNIZATION PERIOD BEGINS
TIME
MONTH
YEAR
MONTH
YEAR
+
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE 07/19/2007
ppinger Falls, NY 12590
CITYITOWN STATE
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIM O. AY YEAR 0 0 RELIGIOUS ~L
~ ~ 9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~ I~ \, 0 ~~
C. LOCATION OF CEREMONY
(CHECK ONE .tN~PECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
SPECIFY lJ...."\) ~e r
ZIP
AM 07
02:22 PM
20
2007
09
17 2007
29. OFFICIANT
NAME (PRINT)
STREET I fT
30. WITNESS TO CEREMONY
"",'W""" ~~ ~"S'<~
SIGNATURE~ ~
tlOH-98 (0312006)
NAME (PRINT)
SIGNATURE~