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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Kri~t~her Ren~UR~~~URNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
COUNTY Dutchess
CITYfTOWN WappinQer
~~~:~c~ 1368 .
~~~I~~~R 19
-.l
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Lisa Marie Hernandez
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 072-66-1833
2. RESIDENCE A New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY lSi/I' TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 621 Sheafe Road, Lot #19~IP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES c1 NO
3. A. AGE ?A 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Laborer
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH Beacon. New York
(CITY, STATE / COUNTRY IF NOT USA)
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Lee
(OPTIONAL - SEE REVERSE) 103 72 3665
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY iY TOWN 0 VILLAGE
~~~CIFY Pouqhkeepsie
D. STREET ADDRESS 3 Hook Road; Apt 72 D ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES r:1 NO
11 /17 /1971
MONTH DAY YEAR
13. A. AGE 35
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Nurses Aide
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH Beacon. New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Rafael Hernandez
. B. COUNTRY OF BIRTH Puerto Rico
17. MOTHER
A. MAIDEN NAME Shirley Ann Castro
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
6. FATHER
A. NAME Robert Lee
B. COUNTRY OF BIRTH Unknown
7. MOTHER
A. MAIDEN NAME Darlene Gail Kilgore
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. ~~~~~~~R~f~M'E<tT8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
(2) 0 DEA"fI1
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 ANNULlLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. ".- YEAR
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
o
o
o
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, dep.ose and say, that to the best of my knowledge and belief that the Information I provided Is true a
as to my right to enter into the ~~Iage~tat . J
21. SIGNATURE OF GROOM~ ;u.t.n.L ru f..,Lg 0 22. SIGNATURE OF BRIDE
USE ENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New State of the bride and groom named above by any person authorized by New York Domestic
Relations Law !Ill 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.
r-I"-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) John C. Masterson
TIME MONTH YEAR MONTH DAY YEAR
SEAL SIGNATURE~ DATE 03/21/200
"-- -.J MAIL.w~ ~D.P.IRF~:>e AM
-v- ~U Mlaall sh Rd, WappinQer Falls, NY 12590 12:44PM 03
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME M . AY YEAR 0 0 RELIGIOUS
DATE AND AT THE TIME AND . 20 AM
PLACE INDICATED. I .J" PM 9 0 OTHER, SPECIFY
7
25. B. SOLEMNIZATION PERIOD
ENDS AT MIONIGHT ON:
22
05
20 2007
2007
28. PLACE WHERE MARRIAGE OCCURRED
l~CIVIL
A, STATE NEW YORK B. COUNTYZ>i.lrt {fiS:,!S
o / ~ f{; tj!/l,iJ;P/Nr" Gie-~
CITYfTOWN
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~VILLAGE OF
SPECIFY Id4/CfO/N6-6l2r;, 1-;;.(/ ~
SIGNATURE~
OOH-98 (0312006)
NAME (PRINT)
SIGNATURE~ It