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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~: 1368 .
~~~I:~R 24
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ashle)l Montanez
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Lisa Albuerme
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)060 58 2450
D. SOCIAL SECURIlY NUMBER _ - -
2. RESIDENCE A. NAW York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY otJ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 47 Robert Lane ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
3. A. AGE ~? 3B. DATE OF BIRTH 07 / 16 / 1974
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)052 64 1002
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY I!l TOWN 0 VILLAGE
~~~CIFY Wappinoer
D. STREET ADDRESS47 Robert Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ 'NO
06 /10 ,%978
MONTH DAY YEAR
13. A. AGE 28
3B. DATE OF BIRTH
4. EMPLOYMENT
A USUAL OCCUPATION Carpenter
B. TYPE OF INDUSTRY OR BUSINESS Mastercraft Contractino
5. PLACE OF BIRTH Bronx. New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Rafael Montanez
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Ramonita Ruiz
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNUUMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Research Assistant
B. TYPE OF INDUSTRY OR BUSINESS Umbach Financial
15. PLACE OF BIRTH Manhattan, New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Eloy Albuerme
'B. COUNTRY OF BIRTHDominican Republic
17. MOTHER
A. MAIDEN NAME Mensa Duran
B. COUNTRY OF BIRTHDominican Republic
18. NUMBER OF THIS MARRIAG'E 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL A~NUUMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
(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) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT
/ /
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.ose and say, that to the
as to my right to enter into the mamage state.
21. SIGNATURE OF GROOM~
o 1ST
o 2ND
o 3RD
o 4TH
lief that the information I provided is true and that I d
o
o
o
DATE 04/11/2007
by New York Domestic
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23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
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 onl for the urpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) John C. Masterson
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE 04/11/2007
MAILlNG.A~DR~$S AM
'-v-I 20 Midoleb 02:12PM 04
STREET ZIP
I CERTIFY THAT 1 SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED,
06
10 2007
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
DAY
YEAR
MONTH
12
2007
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY W,sjc:H.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~TOWN OF 0 VILLAGE OF
SPECIFY 6 "tuJ:> Cal:.
NAME (PRINT)
SIGNATURE~
DOH-98 (03/2006)
NAME (PRINT)
SIGNATURE~