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COUNTY Dutchess
CITYfTOWN WappinQer
~~~:~c; 1368 .
~~~I:~~R 15
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
1. A. FULL NAME
Rry~n Mich~el Delaado
MIDDLE cu ENT SURNAME
FROM THE BRIDE
Andrea D Delgado
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Denegal
c. SURNAME AFTER MARRIAGE Delgado
(OPTIONAL - SEE REVERSE) 098 68 7669
D. SOCIAL SECURITY NUMBER --
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY D TOWN cY VilLAGE
~~CIFY Wapoinaers Falls
D. STREET ADDRESS 1548 Route 9; Apt 1 c ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? tf YES D NO
05 /10 /1972
MONTH DAY YEAR
11. A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
D. ~:'~~~~:~::e~~RSE) 124-56-2008
2. RESIDENCE/\. New Ynrk B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY D TOWN ~ VILLAGE
~~CIFY Wappingers Falls
D. STREET ADDRESS 1548 Route 9: Apt 1 c
ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? cY' YES D NO
3. A. AGE ~? 3B. DATE OF BiRTH On / 05 / 1974
MONTH DAY YEAR
13. A. AGE 34
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION P~rt!=: Advi!=:or
B. TYPE OF INDUSTRY OR BUSINESS Automotive
5. PLACE OF BIRTH 8mnx. ~":aw York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Rnhert nelg~rln
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME .Janet Cohen
B. COUNTRY OF BIRTH LJ S A
B. NUMBER OF THIS MARF,UAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATION Human Resources
B. TYPE OF INDUSTRY OR BUSINESS Not-for-profit
15. PLACE OF BIRTH Brook!vn. Ne'.... York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Jimmy Lee Denegal
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Elaine I. Walker
B. COUNTRY OF BIRTH USA
1 B. NUMBER OF THIS MARRIAGE 2
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~
9 PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
. A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT DEATH DIVORCE CIVil ANNULMENT DEATH
1 0 0 1 0 0
B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) D ANNULMENT (2) D DEAJH B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 01/ 04 / 2002 C. DATE LAST MARRIAGE ENDED? 01 / 04 / 2002
MONTH DAY YEAR MONTH DAY'. . - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 o(es 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? D~ES D NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 01/04/2002 Poughkeepsie. New York D.... D 1ST 01/04/2002 PouQhkeepsie. New York D ct'
2ND D D 2ND D D
~ D D ~ D D
~ D D ~ D D
I duly swe!lr/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal im ediment exists
as to my nght to enter Into the ma
21. SIGNATURE OF GROOM 22. SIGNATURE OF BRIDE~
US
23. SUBSCRIBED AND SWORN TO/AFFIRMED B FORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New State of e 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.
D If checked, this license is to be used only for the urpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
by New York Domestic
~
{ SEAL }
'-v-I
NAME (PRINT)
MONTH
YEAR
YEAR
TIME
MONTH
DATE 03/07/200
in er Falls NY 12590
STREET C rro N 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. DAY YEAR 0 JK RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 7J tK} P 9 D OTHER, SPECIFY
~~~:~~~~ P,t! ~t-v~/.!/J /... ~ #Vr./! TITLE hs:7O'.I\
SIGNATURE~ ~ ~~~./~~ DATE 3h'...z./&7
MAILING ADDResS ' ~
iR1:/ 'S"t?u/H A~!"?fT~h'''~A-G-f~ M#'~i-E~/Y /~S"C;Z~
.r"vI ~ 31. WITNESS TO CEBEMON:
, V\ NAME (PRINT)
AM
06:0&M
03
08
2007
05
06 2007
2B. PLACE WHERE MARRIAGE OCCURRED
1 D CIVIL
A. STATE NEW YORK B. COUNTY L?~#4"~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF D TOWN OF a. VILLAGE OF
SPECIFY MA''p'''''//'!.l(-,'f~< /'/lMS
t"
SIGNATURE~