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COUNTY Dutchess
CITYfTOWN Wappinqer
~~~::f: 1368 .
~~~I:~~R 27
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Pp.tp.r .Josp.ph Franolich
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
1 . A. FULL NAME
1 1. A. FULL NAME
o SUPPLEMENTAL FILE
FROM THE BRIDE
Fanny Cecilia Rodriguez Quezada
FIRST MIDDLE CURRENT SURNAME
.-J
L
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 090 52 5648
D SOCIAL SECURITY NUMBER _ - -
2. RESIDENCEA. Np.w York 8 Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY III TOWN 0 VILLAGE
~~~CIFY Fishkill
D STREET ADDRESS 3H Fishkill Glen ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES f!'5 NO
3. A. AGE 45 3B. DATE OF BiRTH 11 /?6 / 1 961
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Franolich
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New Y ork
(STATE)
c. CHECK ONE 0 CITY I!f TOWN 0
~~~CIFY Fishkill
D. STREET ADDRESS 3H Fishkill Glen ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ jNO
13. A. AGE 40 3B. DATE OF BIRTH 04 /04 /190.7
MONTH DAY YEAR
B. Dutchess
(COUNTY)
VILLAGE
4. EMPLOYMENT
A. USUAL OCCUPATION Mp.chanic
B. TYPE OF INDUSTRY OR BUSINESS Royal Carting
PLACE OF BIRTH Bronx. New York
(CITY, STATE / COUNTRY IF NOT USA)
FATHER
A. NAME Pp.tp.r Mich::lp.1 Franolich
B. COUNTRY OF BIRTH USA
MOTHER
A. MAIDEN NAME Helga Schiffmann
B. COUNTRY OF BIRTH Germany
NUMBER OF THIS MARF,lIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATION Nurse
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH Giron, Ecuador
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Rodrigo Rodriguez
'B. COUNTRY OF BIRTH Ecuador
17. MOTHER
A. MAIDEN NAME Florencia Quezada
B. COUNTRY OF BIRTH Ecuador
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
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) c(D1VORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 01/ 04 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 0 NO
10. 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
01/04/2005 Poughkeepsie. New York
DEATH
o
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
(2) 0 DEATH
2005 '
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) (CITY/COUNTY, STATElCOUNTRY. IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I dulyswear/affirm, depose an
as to my right to enter into th
21. SIGNATURE OF GROOM ~
o rf 1ST
o 0 2ND
o 0 3RD
o 0 4TH
ge and belief that the information I provide
e
o 0
o 0
o 0
o 0
declare that no legal impediment exists
22. SIGNATURE OF BRIDE
USE CURRENT NAME
w
U)
Z
W
o
::i
USE
23. SUBSCRIBED AND SWORN TO/AFFIRM BEFORE ME 04/25/2007
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New '(i rk 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 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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ }. NAME (PRINT) John C. Masterson TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ DATE 04/25/200
MAILING ADDRE,?S AM
'-v-I 20 Midal ush Rd, Wappinqer Falls, NY 12590 12:35>M 04 26 2007 06 24 2007
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER. '---.L'
SONS NAMED ABOVE ON THE TIME MO. AY YEAR 00 RELIGIOUS 1~ CIVIL
DATE AND' AT THE TIME AND SO
PLACE INDICATED. __ () 7 9 0 OTHER, SPECIFY
YEAR
29. OFFICIANT
NAME (PRINT)
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYD 1J.~Jl ,,~<..
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY-U.1..tf'1 "--9 e r
NAME (PRINT)
SIGNATURE~ '