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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jaime Daniel Morillo
USE CURRENT NAME 0412112006
DATE
in New York Stat of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within W 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 cl3di1W'C Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) ~.
SEAL /1~ 0412112006 TIME MONTH DAY YEAR MONTH
SIGNATURE~_ _Lo_ DATE
'-.,-' MA2tf"'lOllClR Rei, ppinger Falls, NY 12590 06
STREET CITYITOWN STATE ZIP
~~~R~~~RT~~~ 6~O!r~~Nif:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 !1' CIVIL
DATE AND AT THE TIMElJN .').0 AM - /
PLACE INDIC.ATED. _ :z -:.... PM ~ 01;) 9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
COUNTY Dutchess
CITYITOW..N V\fapPInger
DISTRICT1~
NUMBER
REGISTER 35
NUMBER
1. A. FULL NAME
MIDDLE
CURRENT SURNAME
FIRST
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B. BIRTH NAME, IF DIFFERENT
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4. EMPLOYMENT
A. USUAL OCCUPATION Engineer
B. TYPE OF INDUl;ll1!Y 9B !!l.!l>lNESli ~:_~. M.
5. PLACE OF BIRTH Mannauan, NeW Vork
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER .
A. NAME Emilio Manila
B. COUNTRY OF BIRTH Domlnicen RepU~lc
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7. MOTHER .
A. MAIDEN NAME Manna AItaIgracia espinal
B. COUNTRY OF BIRTH Dominican RepubliC
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1V'fjCE CIVIL ANrfLMENT
DEtJH
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
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STATE FILE NUMISI:H
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
-F/ilQM THE BRIDE
Nhan T. LN
11. A. FULL NAME
MIDDLE
CURRENT SURNAME
FIRST
B BIRTH NAME (MAIDEN NAME), M8MIW
C. SURNAME AFTER MARRIAGE .....~
(OPTIONAL - SEE REVERSE)628-.;JU"~
D. SOCIAL SE~'8ik DlJtclless
12. RESIDENCE A. (ST.) B. (COUNTY)
C. CHECK Ollli.___.D.. CITY 0 TOWN 0 VILLAGE
AND aRaJJl
SPECIFY 158 Van Cortland Circle 12508
D. STREET ADDRESS z~
E, IS RE'WCE WITHIN LIMITS OF CITY OR INCORPORATlifIUAGE? 12 0 'iib.~ NO
13. A. AGE 13.B. DATE OF BIRTH L. ~
MONTH DAY YEAR
14. EMPLOYMENT E'
A. USUAL OCCUPATION ngI~. 8. M.
B. TYPE OF INDUfI&fvtBin
15. PLACE OF BIRTH '
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER Bao Le
A. NAME VI'"
11111
B. COUNTRY OF BIRTH
17. MOTHER Suong Ngo
A. MAIDEN NAME Vietnam
B. COUNTRY OF BIRTH 1
1 B. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI'6RCE CIVIL A"tfLMENT
DE(fH
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
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
2ND
3RD
4TH
f that the information I provided is true and that I decl
o 0
o 0
o 0
o 0
ediment exists
YEAR
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~ tj ICfJ fJS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY an- Hr/'fL~ ~C-
NAME (PRINT)
SIGNATURE~