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COUNlY Dutchess
CITYrrOWN WappinQer
~~J~~c: 1368 0
~~~~J~R 176
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Willi;;laJDL!oseph SI~U~~E~-rStJJ~E
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jenifer Frances Borba
MIDDLE CURRENT SURNAME
..J
1 0 Ao FULL NAME
11. A. FULL NAME
FIRST
0..
N
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 058 72 5195
Do SOCIAL SECURITY NUMBER_ - -
2. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY D TOWN ~ VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 10 Park Avenue ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? cr YES D NO
3. A. AGE ~o 3B. DATE OF BiRTH 11 /?R / 1 ~7!)
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE S u II iva n
(OPTIONAL - SEE REVERSE) 025 56-2139
D. SOCIAL SECURITY NUMBER -
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY D TOWN [!" VILLAGE
~~CIFY Waooinaers Falls
D. STREET ADDRESS 10 Park Avenue ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? ~ YES D NO
13. A. AGE ~4 3B. DATE OF BIRTH 06 /05 /'1972
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Alltomotive Oet;;liler
B. TYPE OF INDUSTRY OR BUSINESS Automotive
5. PLACEOFBIRTH Yonkers. New York
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Willi;;lm J Sulliv;;ln
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Nilda Ester Matos
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
14. EMPLOYMENT
A. USUAL OCCUPATION Dental Technician
B. TYPE OF INDUSTRY OR BUSINESS Dental
15. PLACE OF BIRTH Bronx. New York
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Rubens Borba
'B. COUNTRY OF BIRTH Brazil
17. MOTHER
A. MAIDEN NAME Maria Carneiro
B. COUNTRY OF BIRTH Brazil
18. NUMBER OF THIS MARRIAGE 2
9. ~~~~d'~R~"'FRp~'llt~8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) cfo,VORCE (3) D ANNULMENT
C. DATE LAST MARRIAGE ENDED? 1 0/ 13 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? OI(ES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLlLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 10/13/1999 Danbury. Connecticut r::Y D 1ST
2ND D D 2ND
3RD D D 3RD
~ D D ~
I duly swear/affinn, deP.Ose and say, that to the best of my knowledge and belief that the infonnation I provided is true
as to my right to enter into the mamage state.
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~'VORCE . (3) D ANNULMENT (2) D DEA'J}f
C. DATE LAST MARRIAGE ENDED? 12 / 18 / 2000
MONTH . DAY. - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES D NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULlLED, PROVIDE THE FOLlLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
12/18/2000 White Plains, New York 0 d
D D
D D
D D
that no legal impediment exists
DEATH
o
(2) D DEA'J}f
1999 '
YEAR
DATE
11/01/2006
by New York Domestic
~
{ } NAME (PRINT)
SEAL. SIGNATURE.
'-v-' MAIL~a ?&~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR MONTH
YEAR
11 02 2006 12 31 2006
2B. PLACE WHERE MARRIAGE OCCU~
A. STATE NEW YORK B. COUNTY ~44n~
c. LOCATION OF CEREMONY
(CHECK ONE ANYECIFY)
D CITY OF ~OWN OF D VILLAGE OF
PECIFY 11/""'1 ~~
r
NAME (PRINT)
SIGNATURE.