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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 R~ymnlJ~dn~F!rh f\~u~re~I~~RNAME
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONLY)
I
COUNTYOlltchF!SS
CITYrrOWN Wappinger
~~~:~:1 ~nR .
~5~~J~R8
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Fevalin Pulmano Egipto
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEL
D. SOCIAL SECURITY NUMBER nRO-!i0-?195
2. RESIDENCE A. NY B. Olltr.hF!ss
(STATE) (COUNTY)
C. CHECK ONE ...0 CITY 0 TOWN 0 VILLAGE
AND
SPECIFY RF!::lr.nn
D, STREET ADDRESS 11 Ralph St ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3, A. AGE53 3B. DATE OF BIRTH 01 /O? /1957
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Retired
B. TYPE OF INDUSTRY OR BUSINESS Corrp.ction Officer
5. PLACE OF BIRTH 8mnv NY
(CITY, STATE I ctJUNTRY IF NOT USA)
6. FATHER
A. NAME Anthony Rayroond ~::lnnF!lI::l
B. COUNTRY OF BIRTH II f\ A
7. MOTHER
A. MAIDEN NAME ThF!rF!~::l Ann .tornan
B. COUNTRY OF BIRTH II f\ A
B. NUMBER OF THIS MARRIAGE 2
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAG~annella
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCE"NY
(ST~)
C. CHECK ONE ~ CITY 0
~~CI~eacon
D. STREET ADDREsJ 1 Ralph St ZIp12bUts
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 110 YES 0 NO
13. A. AG~9 3B. DATE OF BIRTH 02 ;1"4 }971
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATIOr-P-Olice Non Commision Officer
B, TYPE OF INDUSTRY OR BUSINESSGovernment
15. PLACE OF BIRTJ::abangan, ZDS, Phi Is
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAMEConstante C. Egipto
'B. COUNTRY OF BIRTfhilippines
putchess
(COUNTY)
TOWN 0 VILLAGE
17. MOTHER
A. MAIDEN NAMEZoraida G. Pulmano
B. COUNTRY OF BIRT~hilippines
18. NUMBER OF THIS MARRIAGE 2
ei'
III
2;
i
Q
~
!
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 Dlie-TH
o 0 1 0 1 u
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) D ANNULMENT (2) ~ DEAJl1 B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) rj ANNULMENT (g), ~ DEATH
C. DATE LAST MARRIAGE ENDED? OR / 09 / ?007 c. DATE LAST MARRIAGE ENDED? 02 / 24 /20U
MONTH DAY YEAR MONTtlIo DAY' .. - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES I!tNO D. ARE ANY FORMER SPOUSE(S) ALIVE? LJ YES 0 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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
D 0 1ST 02/24/2005 Pagadian City. Philippines 0 ~
o 0 2ND 0 D
o 0 3RD 0 D
o 0 4TH 0 D
d e and belief that the information I provided Is true and that I declare tha! no legal impediment exists
.~
DATE 02/18/2010
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.ose and
as to my right to enter into the
21, SIGNATURE OF GROOM~
SECU
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 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 urpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
by New York Domestic
r-^-.
{ } NAME (PRINT)
SEAL SIGNATURE ~
MAILING ADDRESS
'-v-' .
YEAR
MONTH
YEAR
MONTH
02
19
2010
04
19 2010
28. PLACE WHERE MARRIAGE OCCURRED .
A. STATE NEW YORK B. couN~NL{5
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF YTOWN OF 0 VILLAGE OF
SPEClrLdtl ft (j I x:r r
1'1 M~D II/ E -z.
NAME (PRINT)
SIGNATURE~