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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Mi~m-el Mar::tu~D~~audry CURRENT SURNAME
COUNTYDutchp-~~
CITYrrowNWappingp-r
~~J~~c~ 1368
~5~~J~R49
1. A. FULL NAME
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE~
D. SOCIAL SECURITY NUMBER _u77-62.-3131
2. RESIDENCEA.N.A~odc B. ~~~e~p-r
C. CHECK ONE o,l] CITY 0 TOWN 0 VILLAGE
AND
SPECIFY Mount Vemon
D. STREET ADDRESS?O I orraine Avenue ZIP 10553
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
JiH /2;ty / ~lB
3B. DATE OF BIRTH
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3. A. AGE27
4. EMPLOYMENT
A. USUAL OCCUPATION Auto Mecbanic
B. TYPE OF INDUSTRY OR BUSINESS Prp-~igp- Imports
5. PLACEOFBIRTH~WJl~f\.~~ Vnnr
6. FATHER
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A. NAME Jesus Rosa
B. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A. MAIDEN NAME Mary E~ilabeth Veaudry
B. COUNTRY OF BIRTH II S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o Il
DEATH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
11. A.
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME Marissa Anne Contreras
FIRST MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Vp.audry
(OPTIONAL - SEE REVERSE) 2
D. SOCIAL SECURITY NUMBER 124-62-493
12. RESIDENCE ANe~X?rk B. DIfi~~S
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRES~ Whiteaate Drive. Unit J
ZIP 12590
DYES '6 NO
1979
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE26 13.B. DATE OF BIRTH 07 n
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Medical Assistant
B. TYPE OF INDUSTRY OR BUSINESS Main st. Health Center
15. PLACE OF BIRTHMount Vernon, New York
(CITY, STATElCOUNTRY IF NOT USA)
16. FATHER
A. NAMEEmilio Contreras
B. COUNTRY OF BIRTtU S A
17. MOTHER
A. MAIDEN NAME Anna Marie Vir.inanza
B. COUNTRY OF BIRTJJ S A
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST
~ 0 0 ~
~ 0 0 ~
~ 0 0 ~
I, being duly sworn, depose and say, that to the best ~m knowledge and belie that the information I provided is true and that I declare th
as to my right to enter into the r i . .
21. SIGNATURE OF GROOM. 22. SIGNATURE OF BRIDE
CURRENT N
23. SUBSCRIBED AND SWORN TO 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 purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL }
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NAME (PRINT)
DATE 0511012006
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
DATE 05/1 1l121l1l6
AM
02:46 PM 05
09 2006
11
2006
07
ZIP
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
NAME (PRINT)
SIGNATURE~
DOH-98 (11/98)
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY WUre.MttI
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF . TOWN OF 0 VILLAGE OF
SPECIFY &~1Jt"'A"" /'I1ltNtlL
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