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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
1 A. FUll NAME Jeffrey Carl Leo
FIRST MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYITOWN Wappinger
~~~~~~ 136B
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B BIRTH NAME, IF DIFFERENT
:s I A I t: t"ILt:. NUMtU:.H
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 1 00-74-3677
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A New York 8. Oranae
(STATE) (COUNi"i'j
C CHECK ONE 0 CITY 1'1 TOWN 0 VILLAGE
~~~CIFY Woodbury
D STREET ADDRESS 17 Alloway Crest ZIP 1 0930
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES!5 NO
12 /31 /1972
MONTH DAY YEAR
3 A. AGE 33
38. DATE OF BIRTH
11 A.
FROM THE BRIDE
FUll NAME Annette Incle
CURRENT SURNAME
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4. EMPLOYMENT
A. USUAL OCCUPATION Attorney
8. TYPE OF INDUSTRY OR BUSINESS Law Ofe. Of Dennis Kenny
5. PLACE OF BIRTH Newburgh, New York
(CITY, STATE/COUNTRY IF NOT USA)
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Gonzalez
c. SURNAME AFTER MARRIAGE Leo
(OPTIONAL. SEE REVERSE) 090-56-9378
D SOCIAL SECURITY NUMBER
12 RESIDENCE A. New York 8. Oranae
(STATE) (coulm)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Woodbury
o STREET ADDRESS 17 Alloway Crest
ZIP 10930
DYES i1 NO
18'66
YEAR
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6. FATHER
A. NAME Carl Leo
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Cozette Dodson
8. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
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E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE?
13. A AGE 39 13.8. DATE OF BIRTH 12 1J6
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Court Reporter
8. TYPE OF INDUSTRY OR BUSINESS NYS Worker's Compo Brd
15. PLACE OF BIRTH Bronx, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Anibal Gonzalez
8. COUNTRY OF BIRTH Puerto Rico
17. MOTHER
A. MAIDEN NAME Carmen Gonzalez
8. COUNTRY OF BIRTH Puerto Rico
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
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8. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C DATE LAST MARRIAGE ENDED? 09 / 10 / 2003
MONTIt,I 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
09/1012003 Sussex Co.. New Jersev
B. HOW DID LAST MARRIAGE END? (3) r1 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 05 / 20 /2005
MONTIt,I DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
2D. 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
OS/20/2005 Goshen, New York
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to t
as to my right to enter into the marriage stat
o ~ 1ST
o 0 2ND
o 0 3RD
o 0 4TH
best of my knowledge and belief that the information I provided is true and that I declare that n
o
o 0
o 0
o 0
gal impediment exists
23. SUBSCRIBED AND SWORN TO BEFORE M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of t e 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
} NAME (PRINT) Jo C. Masterso
{ ~ TIME MONTH YEAR
SEAL SIGNATURE ~ L DATE 01/11/2006
'-.,,-I M~~~fdfi ush Rd, Wappinger Falls, NY 12590 06:20 ~~ 01 12 2006
STREET CITYITOWN 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 o~
DATE AND AT THE TIME AND
PLACE INDICA TED.
21 SIGNATURE OF GROOM ~
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by New York Domestic
MONTH
YEAR
03
12 2006
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK 8. COUNTJ:.riI7tJ5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 91 VILLAGE OF
SPECIFUPflttl6?Er:5 -/i4-tif.
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SIGNATURE ~
DOH.98 (11/98)
ZIP
31 WITNESS T~EREMONY
NAME (PRINT) e/ \, l ~T\
SIGNATURE~ ...e~
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