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" I'" I E: ur PfE: VV ,un",
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
G;:!hriel Montiel
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinqer
~~~~~: 1368 .
~~~I:~~R 8
1 . A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 963 75 3633
D. SOCIAL SECURITY NUMBER ___ - -
2. RESIDENCE A. New York B. DIJtchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY Wappingers Falls
D STREET ADDRESS 69 East Main Street; Apt 1 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? r!! YES 0 NO
3. A. AGE ~~ 3B. DATE OF BiRTH On / 23 / 1973
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION How;ekeeping
B. TYPE OF INDUSTRY OR BUSINESS Hospital
5. PLACE OF BIRTH Puebla Mexico
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME A;:!ron Montiel Hern;:!nne7
B. COUNTRY OF BIRTH Mexico
7. MOTHER
A. MAIDEN NAME Esperanza. Lara Madrid
B. COUNTRY OF BIRTH Mexico
8. NUMBER OF THIS MAR81AGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
(THIS SPACE FOR STATE USE ONLY)
Nor
use f)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FIRST RemedL?o~Lf-guayo Ec~~~~PS~~AME
--1
11. A. FULL NAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Montiel
(OPTIONAL - SEE REVERSE) 963 75 3635
D. SOCIAL SECURITY NUMBER --
12. RESIOENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY Wapoinaers Falls
D. STREET ADDRESS 69 East Main Street; Apt 1 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF :CITY OR INCORPORATED VILLAGE? t1 YES 0 NO
09 /01 /1974
MONTH DAY YEAR
13. A. AGE 32
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
3B. DATE OF BIRTH
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Puebla. Mexico
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Jose Aguayo
'B. COUNTRY OF BIRTH Mexico
17. MOTHER
A. MAIDEN NAME Petra Espinosa
B. COUNTRY OF BIRTH Mexico
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, th
as to my right to enter into the marn
21. SIGNATURE OF GROOM~~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
the best of my knowledge and belief that the information I provided is true and that I d
te.
22. SIGNATURE OF BRIDE ~ X
o D
o D
o 0
o 0
hat no legal impediment exists
US
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New ~ rk 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 only for the purpose of a second or subsequent ceremony,
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) J C. Masterson
w
C/)
Z
W
o
:J
r-"-,
{ SEAL }
'-.t-'
DATE
02/02/2007
by New York Domestic
TIME
YEAR
MONTH
YEAR
MONTH
SIGNATURE ~
MAILING ADDRESS
20 Middl
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE 02/02/200
ush Rd. Wapoinqer Falls, NY 12590
C1TYITOWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 0 RELIGIOUS
AM
PM 9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
TITLE
SIGNATURE ~
MAILING ADDRESS
DATE
STREET
30. WITNESS TO CEREMONY
CITY fTOWN
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
STATE
AM
01:1 DPM
2007
04
03 2007
02
03
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~