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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 Angel ~~lonio Nori~~R~NT~~NAME
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONLY)
I
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~; 1368
~~~I~~~R 1 0
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jennifer Amber Gloyd
MIDDLE CURRENT SURNAME
~
11. A. FUll NAME
FIRST
ll.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Noriega
(OPTIONAL - SEE REVERSE) 134-74-2079
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY Wappinqers Falls
D. STREET ADDRESS 26 W. Academy St., Apt. 3 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
11 /01 /1981
MONTH DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 111 70 1112
o SOCIAL SECURITY NUMBER --
2. RESIDENCEA. New York B. Ulster
(STATE) (COUNTY)
C. CHECK ONE 0 CITY !'i!1 TOWN 0 VILLAGE
~~~CIFY Lloyd
o STREET ADDRESS 108 Cotter Road
ZIP 12528
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES!!1' NO
11 / 12 / 1985
MONTH DAY YEAR
13. A. AGE 25
3. A. AGE ?1
3B. DATE OF BIRTH
3B. DATE OF BIRTH
~
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4. EMPLOYMENT
A. USUAL OCCUPATION Security Officer
B. TYPE OF INDUSTRY OR BUSINESS American Citadel
5. PLACE OF BIRTH Bronx. New York
(CITY, STATE / COUNTRY lF NOT USA)
6. FATHER
A. NAME Angel Antonio Noriega
B. COUNTRY OF BIRTH Puerto Rico
7. MOTHER
A. MAIDEN NAME Marisol Colon
B. COUNTRY OF BIRTH Puerto Rico
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Billinq Assistant
B. TYPE OF INDUSTRY OR BUSINESS Healey Brothers
15. PLACE OF BIRTH Mount Kisco, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Michael Glovd
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Linda Todd
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
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (,
MONTH DAY YEAR
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
C. DATE LAST MARRIAGE ENDED?
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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
Cl
<(
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided i
as to my right to enter into the marr stat ~
21. SIGNATURE OF GROOM ~
w
w
a:
In
USE C
23 ~~rJ;:T~~~Do~N.flo~';:;06'~ ~~A6r:f~E~ BEFORE ME DATE 02/09/2007
This license authorizes the marriage in New York State of t authorized by New York Domestic
Relations Law !l11 to perform marriage ceremonies within New York te. 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) Joh
~
{ SEAL }
'-v-I
YEAR
MONTH
YEAR
TIME
MONTH
DATE 02/09/200
appinqer Falls, NY 12590
CITYITOWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 0 RELIGIOUS
9 0 OTHER, SPECIFY
SIGNATURE.
MAILING ADDRESS
20 Middlebu h Rd.
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
~~
29. OFFICIANT
NAME (PRINT)
1 0:41AM
PM
10
2007
04
10 2007
02
CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~Vc ~J.fi".\b
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY /I.J ArPP. l="~ I\')~ ~_ ,
NAME (PRINT)
SIGNATURE.
DOH-98 (0312006)
ZIP
31. WITNESS T~EREMONY
NAME (PRINT) ~,..,,- pe>t.J I"JS
SIGNATURE. c:i.?~ p,. u ~