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DISTRICT
NUMBER
REGISTER
NUMBER
~ I '"' II:: vr I~I:: YV 'unr\.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Santos Raymond Santia~o
MIDDLE CURRENT SUR AME
FIRST
COUNTY Dutchess
CITYfTOWN Wappinger
1368 .
1
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
ChM~~J Ann Ca~~~~!t~uRNAME
-.J
1 . A. FULL NAME
11. A. FULL NAME
FIRST
..
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 105-72-9725
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 ~OWN 0 VILLAGE
AND W .
SPECIFY applnger
D STREET ADDRESS 6 B Chelsea RidQe Drive ZIP 12590
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Santiago
(OPTIONAL - SEE REVERSE) 075-76-6601
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 ~OWN 0 VILLAGE
~~~CIFY Wappinqer
D. STREET ADDRESS 6 B Chelsea Ridge Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 31 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Supervisor
B. TYPE OF INDUSTRY OR BUSINESS I. B. M.
5. PLACE OF BIRTH Peekskill. New York
(CITY. STATE / COUNTRY IF NOT USA)
o YES D~O
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
AGE 1 9
3B. DATE OF BIRTH
o YES D~O
07 / 23 / 1987
DAY YEAR
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Waitress
B. TYPE OF INDUSTRY OR BUSINESS Friendly's Ice Cream
15. PLACE OF BIRTH Town Of Corlandt, New York
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME
16. FATHER
Santos Santiago
Puerto Rico
A. NAME Emanuel Capicotto. Jr.
B. COUNTRY OF BIRTH USA
17. MOTHER
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
A. MAIDEN NAME Jean Louise Hanik
B. COUNTRY OF BIRTH USA
1
Beverly Jean Elston
USA
1
1 B. NUMBER OF THIS MARRIAGE
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END?
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) (CITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
(iil;~!u~'--~
DATE 01/16/2007
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USE CURRE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the ride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York Stat. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl for the purpose of a second or subsequent ceremony.
r-"-. 24. TOWN OR CITY CLERKn C. M 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRIND
TIME MONTH YEAR
SEAL SIGNATURE ~ DATE
'-v-I MAILI~dD~Fd~ 01:~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
17 2007
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
03
01
17
200
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY W,..t;TCHE'!Jf,
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ;8 VILLAGE OF
SPECIFY () ~ ~ ; Irt i \1\ .:1
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~