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1 . A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~gn Vir.tnL
I
STATe FILE NUMBI:ft
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY Dutchess
ClTYrrOWN Wappinger
~~~~ 1368
~5~1:J~R 69
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULLNAME Ir~ul CFistiAa~es
CURRENT SURNAME
CURRENT SURNAME
...
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAG~ 4eAles
(OPTIONAL - SEE REVE ..
D. SOCIAL SECURITY NUMBER
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
D. =:~~;~U~~~RSE) 048-98-74811
2. RESIDENCE A Np.w V nlY B. n.drhess
(STATE) --,mJIlffl'
C. CHECK ONE 0 CITY f!!f TOWN 0 VILlAGE
AND W .
SPECIFY applnger
D. STIlEET ADDRESS 13 Seneca Lane ZIP 12~Qn
E. IS RESIDENCE WITHIN UMITS OF CITY DR INCDRPORAlED V1LLAGE'I 0 YES ~ NO
3. A. AGE 4.7 3B. DATE OF BIRTH MJi / ~ / Jj5S
4. EMPLOYMENT
A. USUAL OCCUPATION Mer.hAnir.
B. TYPE OF INDUSTRY OR BUSINESS All Transmission~
5. PLACE OF BIRTH Palmira, Colombia
(CITY, STATE / COUNmY IF NOT USA)
12. RESIDENCE A. N.~eFk B. D~33
c. CHECK ONE 0 CITY [ilf TOWN 0 VILlAGE
AND u. .
SPECIFY -applRger
D. STREET ADDRESS 13 Seneca lane ZIP 1259g
E. IS RESIDENCE WITHIN UM1TS OF CITY OR INCORPORATED VILLAGE? 0 YES Ii2 NO
~ 4l'AY 197'"
3B. DATE OF BIRTH
13. A. AGE a2
14. EMPLOYMENT
A. USUAL OCCUPATION Hoyeewife
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Mo~~n~~_bia
(CITY, TE / )
16. FATHER
6. FATHER
A. NAME Luis Vir.tOriA
B. COUNTRY OF BIRTH Colombia
7. MOTHER
A. MAIDEN NAME Olga Florez
B. COUNTRY OF BIRTH Colombia
6. NUMBER OF THIS MARRIAGE 4
A. NAME Elmer MORtee
B. COUNTRY OF BlRTHColombia
17. MOTHEfl
A. MAIDEN NAME Eucalis Ocampo
B. COUNTRY OF BllffilColombia
-16. NUMBER OF THIS MARRIAGE "}
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 DEATH
3 (] n 1 0 g
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNUlMENT (2) 0 DEATH B. HOW 010 LAST MARRIAGE END? (3) I!I'DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTH 115 / 6!~ / ~~ C. DATE LAST MARRIAGE ENDED? MoonP4 / 1.~ /2QIJi
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? IirYES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVlDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITYICOUNTY, STATEJCOUNTRY,IF NOT USA) 5aF SPOUSE (MONTH. DAY, YEAR) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
1ST 03/11/1993 White Plains, New York 0 ~ 1ST fl4/11f"}nn~ Mnnt~n~gro, Colombia Iir 0
2ND 1110912000 New York County, NY r!1 0 2ND 0 0
3RD 0511912006 Palmira Circle, Colombia 0 ~ 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, depose and sa I that to the best of m owled!e and belief that the information I provided is true and tha~tJCIc.m.sare _.that n~egal impedr~nt exists.
as to my right to enter into t ma ge state. \.) ~ .... -- J'{.
21. SIGNATUREOFGROOM~ 0 ~ 22. SIGNATUREOFBRlDE~I.set \'\'v\.C{ D\A'I\e
USE C ,USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BE RE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE D6JOS!2006
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS UCENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the pu ose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) John C. Maste TIME MONTH YEAR MONTH
SEAL SIGNATURE ~
'-t-I M~Ur~al~ :: 06 06 2006 08 D4 2006
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
.
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
26. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY J}iJ1C/I~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF J4 TOWN OF 0 VILlAGE OF
SPECIFY aI IJpp 11\J~fR.