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1. A. fIlI.L NME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Emilio Carlm; Chaluiun
flIlST MlDIlI.E CURRBIT SURNAME
I
STAlE FILE NUIIBER
(THIS SPACE FOR STATE USE ONLY)
I
COUNTY Dutchess
ClTVITOWN WaDDinaer
:=r 1388
~55
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11.1<. AlLLIWIE ~rJtonja GSWdo
CURRENT SURNAME
IL
N
B. IIIRl1i NAME (IIAIIlEN lWlEI. IF DlFFERBIT
c. ~~s.phaluisan
D. SDCW.SBBI1YHllMIIER OR1-58-R544
1~ RfS1D9lCEf< N.Xodc B. ~I
C. OHEa{ONE 0 CITY il TOWN 0 VILlAGE
=ClFY WAppi~
D. STREET ADIlRESSggD SMrborntlgt\ LA~ 2lP 12590
E. IS RalII:lmCE WI1HIN UMIJS OF CITY OR INCORPORATED VIllAGE? 0 YES otI NO
13. A. AGE 39 38. DATE OF BIRTH L ~Y _
14. EMPLOYMENT
A USUAL OCCUPAnON Manager
B. lYPE OF INDUSTRY OR BUSINESS at IJ fleets HospItal
15. PlACE.OFBlRTH.~JW<<X.
16. FATHER
A NAME Jose VJdal Cdlado
B. COUNTRY OF enm{)omlnlcan Repl.bllc
17. MOlltER
A. MAlDe.l NAME ~NI'\~ TorplC.
B. COUNTRY OF BIRTH Domil'iCflo p~ .blic
18. NUMBER OF THIS MARRIAGE 1
B. BIRTH _.IF lJIFlFSREIff
C. SURNAMEAABUWllIlAGE
D. ~~097-56-7942
2. REsmau:u Ne.wVnrIr B. nlltMA<<C
.(STA~ ~
C. CHEQ(lJNE D CIty ~ roWN 0 VILlAGE
NfD Wa .
SPEGIFY ppnger
13. S11lEEr AOIlfIESS 390 Sc8rborough lane 1Il' 12590
E. IS RESIDENCE WI'l'HIN lOinS OF cnv OR lNCOIlPORATED WJAGE? 0 YES ~ NO
s. A AGE 31 3B.OAlEOFBIRTH~
4. EMPlOYMENT
A. USUAl OCC'lJPA11ON nrivN
B. 'M'E OF INDUSTRY OR BUSfiESS WMte M8na~Ant
5. PLACE OF BlR1H Bronx, NIMI Vork'
(OI1Y, 8mlE lOOUN1RV IF NOT USA)
6. FATHER
A. NAME CartnK ~hall..n
B. COUN1RV OFBlRlH Puerto Rleo
l-
S;
<C
C 7.
...i:
~I&.
i<C 6.
~
o
MOlHffi
A MAIDEN NAME MAriA DolOI'M Cn..D!
8. COI.lNTRY OF BIRTH Pu8rtn Rieo
NUMBER OF llilS IIAHRIAG'E 2
lii
9. PREVIOUS M~AGES 19. PREVIOUS MARRIAGES
A. NUMBBi OF PREViOUS ~ WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DlIlORCE OIVjL AMNULMENT DEATH DIVORCE CIVIL ANNULMENT
1 0 0 0 0
B. !lOW OIllI.AST t.MIllAGE END? (3) ~ DIVORCE (3) 0 ANNUlMB/T (2) 0 DEAlH B.. HOW DID lAST MARIllAGE END? (3) 0 DIVORCE (3) 0 ANNUlJIENT (2) 0 DEAn!
C. DAlELASTIMRHIAGEBmBJ? UCJN1'H04 / !Jj / ~ C. DAlELASTMARRlAGEENDEO? MONTH / DAY / YEAR
D. ARE ANY f'ORMER SPOUSE(S) ALlVF! ~YES 0 NO D. ARE ANY FOFlMER SPOUSE(S) AUVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED 'OR AlIlNUl1ED. MOVlDE lHE FOllOWING INFORMATION 20. IF PREVlOUSLV DlVORCED OR ANNUllED, PROVIDE THE FOU.OWING INFORMATION
DAlE OF DECREE P!ACE ISSUED AGAINST WHOM DAlE OF DECREE PLACE ISSUED AGAINST WHOM
(MClNlll. DAY. \'EM) I(Cm'JOOOrnY. STA1EIOOUN11IY.lF ftOT USA) SELF SPOUSE (MONl1i, WtY. YEARI (ClTYIOOUNTY. STA1E/COlJN1RY, IF NOT USA) SElF SPOUSE
1ST 04I05f2006 Poughlcee.psle. New YorIc 0 ~ 1ST 0 0
~ 0 0 ~ 0 0
~ 0 0 ~ 0 0
4lH 0 0 4TH 0 0
I dUly swear/affinn. d9P-Ose ,and sa~Y1' . the my Imow!edge and belief that 1he information I provided is true and 8ll!that no legal impediment exists
as to my right to enter into :the marn . 1\
2.. SIGNATURE OF GROOM~
USE
23. SUBSCRIBB) AND SWORN TOIAFflRMED BeoRE ME
SlGNA1URE OF TOWN OR CITY Cl.EftK.
This license 8.IilhlJriz8s lfte !/llBl'I'iage in New York State of the
Relations Law ~11 to pelifGl11'1 mamalJ8 amlmonies wilhin New York
o U checked. this license is to be used on
.,.-'1-,. } ::::~:I:C:JohC.~~
{ SEAL.. :GNATlJFlE. (!. DAlE 05I'22f)[][)S
'-v-i' :s'! I Rd ppi~Falls. ~A,J2590 ZlP
~~~~:RT'=- '.W!r':N:26. SOLEMNlZAnONOCCURRED 27. TYPE OF CEREMONY ~
SONS NAMEDABOIIE ON THE 11 DAY YEAR 0 0 RELIGIOUS 1 IVIL
!~ft.~ ~glt.~~~ TIME AND / 9 0 OTHER. SPECIFY
DEATH
o
USE CUR/lS'lT NAME
DAlE O5I??noos
by New York Domestic
ride and groom. named above by any person authorized
THIS UCENSE VALID IN NEW YORK STAlE ONLY.
for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
TIME
-YEAR
07 21 2008
28. PLACE WHERE MARRIAGE OCCURRED
STAlE NEW YORK B. cou~ ~ Iu~.
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o VlLLAGE OF
SPECIFY
. ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) f!t--/tl ~ ~ IfIJ (, CA; .t' JtQ.J'V
SlGNAlURE~ / - .