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1 A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
D. Alber:teJn~vera
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutchess
CITYITOWN Wappinger
~~~~~c~ 136B
~E~I~J~R 28
L 0 SUPPLEMENTAL FILE
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FROM THE BRIDE
11 A FULL NAME M~ Del f<osaJiiad3~lIardo
CURRENT SURNAME
CURRENT SURNAME
Il.
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B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE I .ver-
(OPTIONAL. SEE REVERSijo'" ..
D. SDCIAL SECURITY NUMBER 07~94-2G1 El
12 RESIDENCE A.N "TATE) B. Otdmbess
c. ~~5CK ONE 0 CITY IJo TOWN 0 VILLAGE
SPECIFY '.I!.'appil'lgcr
D STREET ADDREss8 Colonial Dri\<e Apt. F4 ZIP 125~)o
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 4;11 NO
fli~NTH 'DAY I~AR
8. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SDCIAL SECURITY NUMBER
2 RESIDENCE A. N ;tATE) 8 Q~~3S
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND
SPECIFY Wappinger
D STREET ADDRESS 8 Colonial Drive Apt. F4 ZIP 1259()
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
M~ / my / taGO
13. A. AGE 40
14. EMPLOYMENT
13.8. DATE OF BIRTH
3. A. AGE 46
4. EMPLOYMENT
38. DATE OF BIRTH
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A. USUAL OCCUPATION Housekeeper
8. TYPE OF INDUSTRY OR BUSINESS
A USUAL OCCUPATION Instructor'! Oper. Machinef}'
8. TYPE OF INDUSTRY OR BUSINESS Unemployed
5. PLACE OF BIRTH c;mJ~~~~W~~OQ{APeru
6. FATHER
15, PLACE OF BIRTH ~~~~_ie>l(Xrcru
16. FATHER
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A. NAME Augusto LWJ@ra Le~'aAo
B. COUNTRY OF BIRTH Peru
7. MOTHER
A, NAME Rodolfo Oswaldo Gallardo
8. COUNTRY OF BIRTt-pcru
17. MOTHER
A. MAIDEN NAME Flol De Maria E~"h::r S~:n::rlL
8. COUNTRY OF BIRTtpenJ
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A MAIDEN NAME HcFlil'ldo Cobcro
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
DEATH
o
(2) 0 DEATH
o
()
o
(2) 0 DEATH
o
8. HOW DID LAST MARRIAGE END?
o
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
YEAR
MONTH DAY
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
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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
o 0
o 0
o 0
o 0
ediment 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 CLEHK'_~7'" 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Joh .=. '. A '. t. 'rI' .
{SEAL SIGNATURE~ ~. ,~I~ DATEnAI""7'''006
MAILING ADDRESS -j.::;1. ~. "1,. 0:. AM
'-.t-' s~TMiddlebush Rd, Wappi~_vfalls, NVSTA1~590 ZIP 0:10 PM 04
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TI E MO. DAY YEAR
DATE AND AT THE TIME AND A
PLACE INDICATED.
MONTH
YEAR
DATE
by New York Domestic
YEAR
TIME
MONTH
l.'t('CIVIL
18 2006 06 16 2006
28. PLACE WHERE MARRIAGE OCCURRED
A, STATE NEW YORK 8. COUNT2l> li~ ~4 ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFyWfLfiP i VI.~p I
~ ~ OC>""" -d' I~
~ ~, '"'''' tt~~ . . - -
LL SIGNATURE ~ s:;
i= MAILING ADDR '"
a: ~ yY\ itid /(' bus b.E&. I Wfl ff ~ Iije~
W REET CITYITOWN )
(,) 30. WITNESS TO CE 0 Y
DATE
DV :d. -;;;-q lJ
STATE ZIP
31. WITNESS TO CEREMONY
L o..V e \' c...
NAME (PRINT)
SIGNATURE ~
NAME (PRINT)