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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
E.rd E. M~~a
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
COUNTY nlJtr.hp.~~
CITY/TOWN Wappingp.r
~~J~~c~ 1 ~RR
~5~~J~R 34
L 0 SUPPLEMENTAL FILE
11. A.
FROM THE BRIDE
FULL NAME Ci~ Ley RiehlM.@d
CURRENT SURNAME
CURRENT SURNAME
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE 'ftezaFina
(OPTIONAL - SEE REVERS~
D. SOCIAL SECURITY NUMBER 533 11 1648
12. RESIDENCE A.N.A~r:k B. D~s
C. CHECK ONE 0 CITY IOii' TOWN 0 VILLAGE
AND
SPECIFY Poughk.epEie
D. STREETADDREss2710 South Road, Unit H 7 ZIP 12S01
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES <Ill NO
Q.Z,.TH '7 DAY 1'9:nt.R
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 071 B4- 94SQ
2. RESIDENCE A. N_Tlork B. ~~IS
C. CHECK ONE 0 CITY <Ill TOWN 0 VILLAGE
AND E bt .
SPECIFY oug eeplle
D. STREET ADDRESS '71 n ~olJth Road. Unit H 7 ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
Ma /~ /w"15
13. A. AGE 35
14. EMPLOYMENT
13.B. DATE OF BIRTH
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3. A. AGE 3f)
4. EMPLOYMENT
A. USUAL OCCUPATION Software Developer
B. TYPE OF INDUSTRY OR BUSINESS IBM Corp
5. PLACE OF BIRTH ""!iW~f!fmT USA)
6. FATHER
A. USUAL OCCUPATION Retail Manager
B. TYPE OF INDUSTRY OR BUSINESS Gr.-en'l Natural Market
15. PLACE OF BIRTH~~l~.w"'~~R
16. FATHER
3B. DATE OF BIRTH
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A. NAME Samuel E. RishmeFld
B. COUNTRY OF BIRTftl S A
17. MOTHER
A. MAIDEN NAME Emily E. BrOWfl
B. COUNTRY OF BIRTIU S A-
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A. NAME Oscar Mezarina
B. COUNTRY OF BIRTH Pen.
7. MOTHER
A. MAIDEN NAME Ada luz ."-bregu
B. COUNTRY OF BIRTH Peru
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
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(2) 0 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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
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1ST 0 0 1ST
~ 0 0 ~
3RD 0 0 3RD
~ 0 0 ~
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true
as to my right to enter into the m~ state.
21. SIGNATURE OF GROOM ~ ~ ' C, 22. SIGNATURE OF BRIDE ~
o 0
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o 0
o legal impediment exists
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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
DATE
by New York Domestic
.-^-..
{ SEAL }
'-v-I
NAME (PRINT)
YEAR
YEAR
MONTH
TIME
MONTH
DATE 04I19/200S
AM
PM 04
20
2006
06
18 2006
ZIP
TA
27. TYPE OF CEREMONY
q)i(..flELlGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY w.,<J'~,A.~J
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 1\ TOWN OF 0 VILLAGE OF
SPECIFY Y D '/' K-t"'l, u/ V]
S T
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TITLERoHLrl (~jfo{;r. ft.~s
DATE 11....102..' ~t:)O '"
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