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COUNTY Dutchess
CITYfTOWN Wappinger
~~~~~c; 1368 '
~~~I~J~R 30
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFRDAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Andres Benny Valderrama
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
-1
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Nicole Gesmundo
MIDDLE CURRENT SURNAME
1 , A, FULL NAME
11, A, FULL NAME
FIRST
FIRST
B- BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 595 50 0306
D. SOCIAL SECURITY NUMBER --
2. RESIDENCEA. Florida B- Palm Beach
(STATIil (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~CIFY Boca Raton
D. STREET ADDRESS 22615 Sw 66th Ave; Apt ZIP 33428
E. IS RESIDENCE WITHIN LIMITS OF CI'IY OR INCORPORATED VILLAGE? n" YES 0 NO
3. A, AGE 29 3B. DATE OF BIRTH 07 / 22 / 197
MONTH DAY YEAR
4, EMPLOYMENT
A. USUAL OCCUPATION Purchasing Supervisor
B. TYPE OF INDUSTRY OR BUSINESS Food Distribution
5. PLACE OF BIRTH Broward County, Florida
(CITY, STATE / COUNTRY IF NOT USA)
6, FATHER
A. NAME Bienvenido Valderrama
B. COUNTRY OF BIRTH Colombia
7. MOTHER
A. MAIDEN NAME Olqa Maria Burqos
B. COUNTRY OF BIRTH Ecuador
8. NUMBER OF THIS MARF,lIAGE 2
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Valderrama
(OPTIONAL - SEE REVERSE) 121-66-9706
D. SOCIAL SECURITY NUMBER
12, RESIDENCEA. Florida B. Palm Beach
(STATE,) (COUNTY)
C. CHECK ONE [!" CITY 0 TOWN 0 VILLAGE
~~~CIFY Boca Raton
D. STREET ADDRESS 22615 Sw 66th Ave; Apt ZIP 33428
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A. AGE 24 3B. DATE OF BIRTH 06 /28 /'1982
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Teacher
B. TYPE OF INDUSTRY OR BUSINESS Palm Beach Cty Sch Dist
15. PLACE OF BIRTH Poughkeepsie, New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A, NAME Vincent Gesmundo
'B. COUNTRY OF BIRTH Italy
17. MOTHER
A. MAIDEN NAME Margherita Rita Boccia
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) dDIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 11/ 02 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? D~ES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
11/02/2006 Fort Lauderdale, Florida 0 d 1ST
o 0 2ND
o 0 3RD
o 0 4TH
est of my knowledge and belief that the information I provided is true and 1
~h
(2) 0 DEATH
2006
YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
1ST
2ND
3RD
4TH.
I duly swear/affirm. dep.ose and say,
as to my right to enter into the marn
21. SIGNATURE OF GROOM ~ ~
22. SIGNATURE OF BRIDE ~
DATE
04/27/2007
23. SUBSCRIBED AND SWORN TO/AFFIRMED
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
W Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK ST TE ONLY.
en 0 If checked. this license is to be used only for the purpose of a second or subsequent ceremony,
Z ~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
W } NAME (PRINT) John C. Masterson
(.) { / TIME MONTH YEAR MONTH
::::i SEAL SIGNATURE ~ DATE 04/27 200
'-v-I MAI~[j"'rOO~~fe 'sh Rd, Wappinger Falls, NY 12590 12:4~~ 04 28 2007 06 26 2007
STREET CITYITOWN STATE ZIP
~~~R~~RT':J IO~O~~~N~Z:~ 28. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~ RELIGIOUS
~~~E ~gIC~~6'E TIME AND AM q C'l 9 0 OTHER, SPECIFY
z.. - ~oi:OO
29. OFFICIANT n/~ C ., '" ,,~
NAME (PRINT) -I(bV. Nr~Nr.... .JI t+ IT' ~
SIGNATURE~ ~.~.".. - ~-
MAILING ADDRESS LJ
"STR~JI'''' ~O\f1 S~" c~~Q.ra f:a..U~ I
30. WITNESS TO CE
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B.COUNTYj)\Jn~l-IE<;S
TITLE
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFY WIt()(J/ N Ci'6.e~ FitLLS-
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
DATE
do
....
SIGNATURE~