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1 A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
O'Mf Rodr.igu~DLE
::; I A I t: t"ILI: NUMtst:H
(THIS SPACE FOR STA TE USE ONL Y)
COUNTYDutchE"~S
CITYrTOWN Wappinger
~~J~~c;1368
~5~I~J~R31
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAMEI 117 Marie Quintana
FIRST MIDDLE
CURRENT SURNAME
CURRENT SURNAME
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B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Rodriguez
(OPTIONAL - SEE REVERSE).,. 77
D. SOCIAL SECURITY-NUMBER u94-56-60
12. RESIDENCE AN V B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~CIFyBeacon
o STREET ADDRESS 125 Catherine Street
ZIP 12508
"'6 YES 0 NO
1~1
YEAR
2 RESIDENCE A. N@iWA,'tOrk B. Dawar
c. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Middletown
o STREET ADDRESS 1 n~ I indp.n A vp.nlJe ZIP 10940
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES~ NO
M~A /2!}y /1~Z6
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
Ai
10
MONTH
13. A. AGE44
13.B. DATE OF BIRTH
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4. EMPLOYMENT
A USUAL OCCUPATION Construction
B. TYPE OF INDUSTRY OR BUSINESS Kirr.hnff C::on~tmr.tion
5. PLACE OF BIRTHt1!mqm~!!lJ MP.Vir.o
, m Y IF NOT USA)
6. FATHER
16. FATHER
A NAMEFduvigis Quintana
B. COUNTRY OF BIRnPuerto Rico
17. MOTHER
A. MAIDEN NAME .luliA .limp.np.7
B. COUNTRY OF BIRT~uerto Rico
18. NUMBER OF THIS MARRIAGE 2
3B. DATE OF BIRTH
DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Packing
B. TYPE OF INDUSTRY OR BUSINESSG. H. Ford Tea Co.
15. PLACE OF BIRTHHumacao. Puerto Rico
(CITY, STATE/COUNTRY IF NOT USA)
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A. NAME Mario Rodnguez
B. COUNTRY OF BIRTH Mexi~n
7. MOTHER
A MAIDEN NAME Carmen Valencia Lopez
B. COUNTRY OF BIRTH Mexico
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
19. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) c1 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
/ / C. DATE LAST MARRIAGE ENDED? 12 / 13 /2002
MONTH DAY YEAR MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 0 1ST 1:7/13"n02 Dutchess Co . N Y t1
o 0 2ND 0
o 0 3RD 0
o 0 4TH
Df my knDwledge and belief that the infDrmatiDn 1 provided is true .~n~)
DEATH
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DEATH
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C. DATE LAST MARRIAGE ENDED?
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1ST
2ND
3RD
4TH
I, being duly SWDrn, depDse and say, that t
as to my right tD enter intD the marriage st
21. SIGNATURE OF GROOM ~
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23. SUBSCRIBED AND SWORN TO BEFORE M
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
DATE
by New York Domestic
~
{ SEAL }
'-v-I
NAME (PRINT)
MONTH
YEAR
YEAR
TIME
MONTH
DATE 1\4./:76/2006
AM
06:03 PM 04
21
2006
06
25 2006
ZIP
STATE
27. TYPE OF CEREMONY
1 ~CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY iJffT('fi:~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF TOWN OF ~VILL~E OF
P(Ji rJfJ.ifR 5 rAt.t-s
ST
I CERTIFY THAT I SOLEMNIZEO
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
TITLE fi./JmElr:. /Oii.'?J:r:!,;'r~:J.
29. OFFICIANT
NAME (PRINT)
c:'-r;J2 S
DATE di;;:nJ.c ~.
,- . /
i~u_s. IV/I,
STATE
SPECIFY
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ZIP
31. WITNESS TO CEflEMONY j') ..
IV (Piemn /C oSns.
NAME (PRINT) / '- I/T "i'
. "7 '-L..../
..1- "7
SIGNATURE ~