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1. A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jessie Roldan
I
STAIt: ~ILI:: NUMDl:n
(THIS SPACE FOR STATE USE ONLY)
~
COUNTY [)~~
CITY/TOW~ wappinger
DISTRICT 1368
NUMBER
REGISTER 10
NUMBER
L 0 SUPPLEMENTAL FILE
11. A.
FROM THE BRIDE
FULL NAME [)emitra Augoustatos
FIRST MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
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N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Roldan
(OPTIONAL - SEE REVERSE) 126-74-1496
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANew York B. [)~~
(STATE) .; (COUNTY)
C. CHECK O~~. Q CITY Q..TOWN l:J VILLAGE
~~~CIFY VVlpplngefS l"all5
o STREET ADDRESS 1548 Route 9 Apt. 8e
B. BIRTH NAME, IF DIFFERENT ..
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)055-58-2692
D. SOCIAL SEC~FJ.ITY NUMBER
2. RESIDENCE A. New York B [)utch~
(STATE) .; (COUNTY)
C. CHECK ON~ . L D. CITY 0 JP~l'J 0 VILLAGE
~~~CIFY vvappngers l"'allS
o STREET ADDRESS 1548 Route 9 APt tse ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE 30 3B. DATE OF BIRTH 07 /28 /1975
MONTH DAY YEAR
ZIP 12590
~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 23 13.B. DATE OF BIRTH 03 ,B9
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Domestic Engineer
YES 0 NO
1.982
YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Manufacturing
5. :~:Y:~~:I:~Uila~lf:ri:~~'Y~~
(CITY, STATE/COUNTRY IF NOT USA)
8. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Manhattan. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Nicholas Augoustatos
8. COUNTRY OF BIRTHGreece
17. MOTHER
A. MAIDEN NAME Christina Bozas
8. COUNTRY OF BIRTHGreece
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
6. FATHER
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A. NAME Luis Enrique Roldan
B. COUNTRY OF BIRTH ~ueno RICO
7. MOTHER
A. MAIDEN NAME Angeles Marie Torres
8. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~CE CIVIL AN&ULMENT
DEATH
o
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
8. 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
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
o 0
o 0
o 0
o 0
I impediment exists
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o 1ST
o 2ND
o 3RD
o 4TH
belief that the information I provided is true
22. SIGNATURE OF BRIDE ~
DATE
0211412006
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23. SUBSCRIBED AND SWORN 0 B FORE ME
SIGNATURE OF TOWN OR T LERK ~
This license authorizes the marriage in New York S te of the' bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies with 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 Cll;Y Q.LER~ Masterso 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) JOnn~. n
{SEAL SIGNATURE ~ . ~ C' ~~. DATE 0211412006 TIME MONTH YEAR MONTH YEAR
'-v-l ~T~Mm~ Rd, WaPli~~~alIS. ~TA~2590 ZIP 11:34 ~~ 02 15 2006 04 152006
~~~R~~~Ri:~ 10~0~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY 2B. PLACE WHERE MARRIAGE OCCURRED
SONS NAMED ABOVE ON THE TIM MO. DAY YEAR 00 19(C1VIL NEW YORK .......... ~\" \ <S
~tI~E~~glt:T;~E TIME AND 0- OG:, A. STATE B COUNT\..l,)"yr' ~,
C.
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIF~fl ~,p ('
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~