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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:kc~ 1368 .
~G~I:~~R 52
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rourke Adam Wickeri
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Magda Lissetle Quezada
MIDDLE CURRENT'SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Wickeri
(OPTIONAL. SEE REVERSE) 102-90-3286
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 1!1 VilLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 2745 West Main Street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
11 /18 /1977
DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 089 62 3083
D. SOCiAl SECURITY NUMBER --
2 RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN I!l VILLAGE
~~~CIFY Wappinqers Falls
D. STREET ADDRESS 2745 West Main Street ZIP 12590
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VILLAGE? r:1 YES 0 NO
09 / 11 / 1978
MONTH DAY YEAR
13. A. AGE 29
3. A. AGE 28
3B. DATE OF BIRTH
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Retail
B. TYPE OF INDUSTRY OR BUSINESS Retail Industry
5. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Jeffrey William Wickeri
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Jacqueline Mary Dion
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
14. EMPLOYMENT
A. USUAL OCCUPATION Retail
B. TYPE OF INDUSTRY OR BUSINESS Retail Industry
15. PLACE OF BIRTH San Salvador, EI Sa~vador,
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Mario Baldemar Quezada Vasquez
'B. COUNTRY OF BIRTH Guatemala
17. MOTHER
A. MAIDEN NAME Maria Amparo Quintanilla
B. COUNTRY OF BIRTH EI Salvador
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHIGH ENDED BY
DI~RCE' CIVIL AN5ULMENT
DE~TH
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
. M'" ~...... ..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
owledge and belief that the information I provided is true and t
'-
o 0
o 0
o 0
o 0
are that no legal impediment exists
W
U)
Z
W
o
::::i
4TH'
I duly swear/affirm, deP.OSe and say, that to the best of my
as to my right to enter into the lage tate.
21. SIGNATURE OF GROOM~ a.
USE
23. SUBSCRIBED.....ND,SW0RN,TOIA: FIRMEIrBEFORE ME
SIGNATURE OF TOWN OR.CITY CLERK ~
This liCense authorizes the marriage in New Yo tate of th bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies wit 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 seClln(l or subsequent ceremony.
~ 24. TOWN OR CITY. C ERKe. M t 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) as
SEAL SIGNATURE~ DATE 06/18/200 YEAR
MAI~ MWl~ ppinger Falls, NY 12590
'-v-I
STREET CITYITOWN
~~~R~~RT~~~ IO~O!#t~N~Z:~ 26. SOLEMNIZATION OCCURRED
SONS NAMED ABOVE ON THE TI MO. DAY YEAR
DATE AND AT THE TIME AND
PLACE INDICATED.
08
17 2007
22. SIGNATURE OF BRIDE ~
USE CURRENT NAME 06/18/2007
DATE
by New York Domestic
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
ZIP
YEAR
l~VIL
28. PLACE WHERE MARRIAGE OCCURRED I (
A. STATE NEW YORK B. COUNTY'\)v~~~
C. LOCATION OF CEREMONY
(CHECK ONE ~ND }PECIFY)
o CITY OF MOWN OF 0 VILLAGE OF
SPECIFY L 'Pr G-revvyf
NAME (PRINT)
SIGNATURE~
nt11-1_OA IO'J. Pltv\&:\