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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c~ 1368
~5~liJ~R 95
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Gerardo Diaz, Jr.
MIDDLE CURRENT SURNAME
;::J I '" I t; rlL.~ ...",mDl;;n
(THIS SPACE FOR srA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Melissa Leigh Vance
MIDDLE CURRENT SURNAME
~
1 . A FUUL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Diaz
(OPTIONAL - SEE REVERSE) 123-60-3303
D. SOCIAL SECURITY NUMBER
12 RESIDENCEA. New York B. Dutchess
(STATE) ..J (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN LJ VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 2579 South Ave
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 083-66-71 04
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN r1 VILLAGE
~~~CIFY Wapl'inaers Falls
D STREET ADDRESS 2579 South Ave ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? dYES 0 NO
08 / 31 / 196
MONTH DAY YEAR
1209U
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 6 YES 0 NO
12 /23 /1976
DAY YEAR
13. A. AGE 29
3 A. AGE 40
3B. DATE OF BIRTH
38. DATE OF BIRTH
MONTH
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
8. TYPE OF INDUSl.RY ,QR I3USI~r;:ss
15. PLACE OF BIRTH I:SUrraIO, New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A NAME James Lester Vance
U~A
B. COUNTRY OF BIRTH
17. MOTHER
Brenda Lynn Laforme
A. MAIDEN NAME
Ganada
B. COUNTRY OF BIRTH I
1B. NUMBER OF THIS MARRIAGE
A. USUAL OCCUPATION Engineer
8. TYPE OF INDUSTRY OR BUSINESS Utility
5. PLACE OF BIRTH New Rochelle, New York
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
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A. NAME Gerardo Diaz
B. COUNTRY OF BIRTH Colombia
7. MOTHER
Yolanda Sanchez
A. MAIDEN NAME
Colombia
B. COUNTRY OF BIRTH
2
8. NUMBER OF THIS MARRIAGE
DEA(r
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVBRCE CIVIL AN"t)'LMENT
DE't)'H
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
YEAR
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
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o 0
o 0
o 0
o 0
gal impediment exists
USE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New rk State Df the bride and grDDm named abDve by any person authDrized
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 JOFfi'f C. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME(P~ ~
- 07/1 20U
SEAL SIGNATURE ~ C.. DATE
{ MAIL~a ush Rd~PPinger Falls, NY 125~~
'-v-'
DATE
by New York Domestic
w
en
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~
TIME
MONTH
YEAR
MONTH
YEAR
09
2006
03:3!fM
PM
07
29. OFFICIANT
NAME (PRINT)
CITY/TOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
3~\S AM 0"1- "22 0<0
HON. JAMES D. PAGONES
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER. SPECIFY
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYt>\i~~~.s
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF )( TOWN OF 0 VILLAGE OF
SPECIFY t>\e.Wo-~ Vr0.~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
1'~ CIVIL
TITLES\JriO!!J~~~ G"A 0v
DATE c.J \)\'j 2.2.) 2.ooCo
''i \2.bO\
ZIP
31. WITNESS TO CEREMONY
SIGNATURE~
DOH-98 (03/2006)
NAME (PRINT)
SIGNATURE~