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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Robert Burgos
FIRST MIDDLE
COUNTY[)ubOh~
CITYiTOWN Wappinger
~~J~~CRT 1368
~Q~~~NR 15
1. A. FULL NAME
CURRENT SURNAME
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)1all::56-1334
D. SOCIAL SECURITY NUMBER Uil""
2. RESIDENCE A. New York B. Dutchess
"""iff ATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY WaDDingers Falls
o STREET ADDRESS 2655 Eest Main street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? r: YES 0 NO
07 /12 /1972
MONTH DAY
3. A. AGE n
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION ShlDdna Clerk
B. TYPE OF INDUSTRY OR BUSINESS U. P. S./ Fed Ex
5. PLACE OF BIRTH North PhIladelphia, PA
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Luis Garda
B. COUNTRY OF BIRTH Puerto Rico
7. MOTHER
A. MAIDEN NAME Esther Burgos
8. COUNTRY OF BIRTH Puerto Rico
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
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
YEAR
YEAR
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
11. A.
FROM THE BRIDE
FULL NAME Ana 8izabeth Alvarez
FIRST MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Burgos
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANew York B. Dutchess
(STATE) .; (COUNTY)
C. CHECK O!'/i. . I:J CITY fF T~rs D VILLAGE
~~~CIFY vvappingers a
D. STREET ADDRESS~ I:8St M81n Street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ 1~n NO
13. A. AGE 33 13.B. DATE OF BIRTH 10 ~ -
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDU~~Y O.a..Bt~JN_E?S 8dor
15. PLACE OF BIRTH tien ~, 8 58IV
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Guadalupe Alvarez
B. COUNTRY OF BIRTHS 581VadOr
17. MOTHER
A. MAIDEN NAME Ana Cella Alfaro Navas
8. COUNTRY OF BIRTHS Salvador
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI'10RCE CIVIL AN~ULMENT DEt)H
B. HOW DID LAST MARRIAGE END? (3) [f DIVORi2 (3) D1gNULMENT2DB3 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTfilf 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~~~) (CITY,~TATE/~U~TRY,JF~~OT~A) SELF SPOU"
1211C11~ New ::san ::s&IV8OOf, 0 0
....
o 0
o 0
o
iment exists
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 tru
as to my right to enter into the marria s te.
21. SIGNATURE OF GROOM ~
SIGNATURE OF BRIDE ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Sta
Relations Law~11 to perform marriage ceremonies within
o If checked. this license is t
~ 24. TOWN OR CITY CLERK
} NAME (PRINT) Ie. Masterson .
{SEAL SIGNATURE ~ f' ~ DATE 03ID6I2006 11~~E
'-v-' MA~~cWS h Rd, Wappinger Falls, NY 12590 .
STREET CITYfTOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26 SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ~
THE MARRIAGE OF THE PER. .
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR RELIGIOUS 1 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
29. OFFICIAN~
NAME (PRINTT J;:. .
of the bride and groom named above by any
ew York State. THIS LICENSE VALID IN NEW
be used only for the purpose of a second se ent ceiemony.
. SOLEMNIZATION PERIOD BEGINS
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NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
by New York Domestic
YEAR
05
05 2006
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY WArPPI ~1./lh f~
NAME (PRINT)
SIGNATURE ~
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