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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Alexander Hernandez
MIDDLE CURRENT SURNAME
COUNIY Dutchess
CITYfTOWN Wappinger
~~J~~c: 1368 '
~~~I~J~R 58
1. A. FULL NAME
FIRST
Q.
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 091 80 9947'
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNlY)
C. CHECK ONE 0 CITY 0 TOWN r!f VilLAGE
~~~CIFY Wappinqers Falls
D. STREET ADDRESS 21 North Gilmore Blvd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? rj' YES 0 NO
3. A. AGE 26 3B. DATE OF BiRTH 07 / 23 / 1980
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Cable Specialist
B. TYPE OF INDUSTRY OR BUSINESS Con Edison
5. PLACE OF BIRTH C&ii, Colornbia
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Gerardo Hernandez
B. COUNTRY OF BIRTH Colombia
7. MOTHER
A. MAIDEN NAME Luz Stella Gomez
B. COUNTRY OF BIRTH Colombia
8. NUMBER OF THIS MARRIAGE 1
9. 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
/ /
(2) 0 DEATH
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) (CITYICOUNlY. STATEICOUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FilE NUMBER
(TH/S SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Bernice Velazquez
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Hernandez
(OPTIONAL. SEE REVERSE) 361-66-0829
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNlY)
C. CHECK ONE 0 CITY 0 TOWN r1 VilLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 21 North Gilmore Blvd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? r1 YES 0 NO
13. A. AGE 28 3B. DATE OF BIRTH 05 /12 /1979
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Legal Assistant
B. TYPE OF INDUSTRY OR BUSINESS Legal
15. PLACE OF BIRTH Chicago, illinois
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Francisco Velaz-.9uez
'B. COUNTRY OF BIRTH Puerto Rico
17. MOTHER
A. MAIDEN NAME Isabel Arroyo
B. COUNTRY OF BIRTH Puerto Rico
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DENH
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. ~ YEAR
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) (CITYICOUNlY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swe!lr/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is true and
as to my nght to enter Into the mama estate.
21. SIGNATURE OF GROOM~ 22 SIGNATURE OF BRIDE~
DATE 06/20/200
h Rd, W ppinger Falls, NY 12590
STATE
27. TYPE OF CEREMONY
o ~lIGIOUS
9 0 OTHER, SPECIFY
TITLE
DATE
USEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Y bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies in 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 CITYJC RK C M t 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) . as erson
{SEAL} SIGNATURE ~
MAI~ WRffdFe
'-v-'
STREET CITYITOWN
~~~R~~RT~~J IO~O~~N~~ 26. SOLEMNIZATION OCCURRED
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR
DATE AND AT THE TIME AND
PLACE INDICATED.
SIGNATURE~
DOH-98 (0312006)
o 0
o 0
o 0
o 0
at I declare that no legal impediment exists
TIME
MONTH
YEAR
MONTH
YEAR
ZIP
06:4cC~
2007
08
19 2007
06
21
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVil
A. STATE NEW YORK B. COUNIY O"'c..V\",,::>~
Vl~,^\ ~
a/I~c4?
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~TY OF 0 TOWN OF 0 VilLAGE OF
SPECIFY
\-\\~\~wV'\
STATE
SIGNATURE~