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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
John Andrew Velasquez, SR.
FIRST MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
Dutchess
COUNTY .
Wappinger
CITYrrO~
DISTRICT 368
~~~~~~R 4
NUMBER
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME Linda' Levi
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT. De Porto
C. SURNAME AFTER MARRIAGE Levi - Velasquez
(OPTIONAL - SEE REVERSE) 112-58-2859
D. SDCIAL SECURITY NUMBER
12. RESIDENCE ANew York B. Dutchess
(STATE) JI! (COUNTY)
C. CHECK OtlL 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY wappinger
STREET ADDRESS?lg Ma~oney Koao
~
CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)121-5D-9745
D. SOCIAL SECiJelTY NU~~ER
2. RESIDENCE A. New york B. Dutchess
(STATE) <V' (COUNTY)
C. CHECK ON!;... 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY wappinger
510 Maloney Road
D. STREET ADDRESS .. . -
ZIP 126U3
.,
o YES 0 NO
1,960
YEAR
'126030
ZIP
D.
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE45 13.B. DATE OF BIRTH 04 "
DAY
"
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO
3. A. AGE48 3B. DATE OF BIRTH 01 /22 /1957
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Window & Door Installation
B. TYPE OF INDlfiRY lfr fftSINEStI'reSldenl - Own Business
5. PLACE OF BIRTH an a an, ew york
(CITY, STATE/COUNTRY IF NOT USA)
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Document Preparer
B. TYPE OF IND'-lS.TRY OIHIUSINESS. eman Allen
15. PLACE OF BIRTHt-"ougnKeepsle, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Robert De Porto, Jr.
B. COUNTRY OF BIRTHU S A
6. FATHER
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A. NAME
B. COUNTRY OF BIRTH
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7. MOTHER 01 at 17. MOTHER .
A. MAIDEN NAME ga ero A. MAIDEN NAME Anne Mane Kidd
B. COUNTRY OF BIRTH pu~rto RICO B. COUNTRY OF BIRTHU S A
8. NUMBER OF THIS MARRIAGE 18. NUMBER OF THIS MARRIAGE 3
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~CE CIVIL A"ftULMENT D;1TH DI~RCE CIVIL A~ULMENT
~ ~
B. HOW DID LAST MARRIAGE END? (3) 0 DIVO'ffi (3) ~NUL.MENT 2d6& DEATH B. HOW DID LAST MARRIAGE END? (3) 0 D1VOf2 (3) ~ fNULMEN"2 ~:f DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? / / 0
MONl"If" DAY YEAR MONT.... DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION'
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
"",,I)ll,li..Q!l""'~l.-r. (CITYh:'iIATElCOIJJ'lTRy..1f NOT ll~A)rk SELF SPOUSE J.MQ~H. 9~""}:'.f~R~ (CITYh!iTATElCOLLNTRv;.lF NOT ~pA) SELF SPOUSE
1ST U~IU~rJl:Jl:J~ ....oug IlteepSle, New TO'" 1ST UL1.t41l~M t-"oug IKeepsle, New TOrk [f 0
2ND 01/Ltf/lUUU l,;armel, New YOrk ~ ~ 2ND 1211112lJlJ3 Luzeme CO.Pe nnsylvani.a. ~ 0
3RD 0 0 3RD 0 0
~H 0 '0 ~H 0 0
I, being duly sworn, depDse and say, thatt he best of my wledge and belief that the information I provided is true and that I declare that no legal Impediment exists
as to my right to enter into the mar age s e. 1,. 0, _ :. _ ^ . L 0 .
21. ,22.SIGNATUREOFBRIDE~ ~ (It.J:)~
f USE CURRENT NAME
DATE 01/1112006
by New York Domestic
DiiTH
23. SUBSCRIBED AND SWORN TO
SIGNATURE OF TOWN OR CI RK.
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 C3b~'fi't: 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) .
TIME MONTH YEAR
SEAL SIGNATURE ~ .
'-v-' M2'trMiiMfebush
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
MONTH
YEAR
03
12 2006
6:41 ~~ 01
2006
12
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY .&/y ()L p~
S REET
30. WITNESS TO EREMONY
NAME (PRINT) :~ .
SIGNATURE.
DOH.98 (11/9B)
,!:)ONCAN
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SIGNATURE ~