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5TATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
T~ Jonathan TnIT'M
FIRST MIDDLE
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare y\at no legal impediment eXists
as to my right to enter into the marriage state. ~ 1 \ PI.' t ~ - ----
21 SIGNATUREOFGROOM"G '...., ~ 22. GNATUREOFBRIDE" AfJI ~
us USE CURRENT NAME
23 SUBSCRIBED AND SWORN TO BEFORE ME 1"'~1'VVY:::
SIGNATURE OF TOWN OR CITY CLERK" DATE QUU",^,~
This license authorizes the marriage in New York State I the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within N York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to I:) used only lor the purpose of a second or subsequent ceremony.
{ ~ } ~:~~~:I~~)~' M~ 25. A. SOLEMNIZATION PERIOD BEGINS
SEAL If''ru,, ~ ~C ~ ~_ "'" 12J112J21l115 ""' "aNn< """ MO"'" m,
'-v-l ST!rUf&i Rd. WaDli~falls. N'!TA~2590 ZIP 02:09 ~~ 12 03 2005 01 31 2008 .
~~~R~~~RT~~~ IO~O~~~N~EE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY 28. PLACE WHERE MARRIAGE OCCURRED
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 1 ~CIVIL .......... ,f... \ - - c
DATE AND AT THE TIME AND A. STATE NEW YORK B. COUN~
PLACE INDICATED. () ~ 0 ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF l1J TOWN OF 0 VILLAGE OF
COUNTY Dutchess
CITY/TOWN Wappinger
~~J~:fJ 1388
~5~~J~R 150
1. A. FULL NAME
CURRENT SURNAME
~IAlt rlLt NUMt5tn
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME f\Iygt Nime ActAcln
FIRST MIDDLE
CURRENT SURNAME
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B. 81RTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)~II.t ..,n '21"v.1o
D. SOCIAL SECURITY NUMBER ~~--~
2. RESIDENCE A New Vark B. nlltMMA
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN oil VILLAGE
~~~CIFY FlShldll
D. STREET ADDRESS 26 RosIlla Lane ~ A ZIP 12524
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE?8 3B. DATE OF BIRTH M91H /OZy /1y%'19
4. EMPLOYMENT
A. USUAL OCCUPATION Software Engjneer
B. TYPE OF INDUSTRY OR BUSINESS I. B. M.
5. PLACE OF BIRTH Ponce PuerID Rico
(CIlY, ST A tElCOUNTRY IF NOT USA)
6. FATHER
A. NAME Tedcty Torres
B. COUNTRY OF BIRTH Puerto Rico
7. MOTHER
A. MAIDEN NAME HeytfAA CoIOF'
B. COUNTRY OF BIRTH PU8lto Rico
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE TnrrM
D S6~~~I~~tULR~T~E~U~~~~RSE) 088-1n.Q458
12. RESIDENCEA.New'VnrIc B. Ot~
(STATE) ~
C. CHECK ONE 0 CITY 0 TOWN rrt VILLAGE
~~~CIFY WappingelS Falls
STREET ADDRESS 13 Creekvlew Court ZIP 12590
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13.8. DATE OF BIRTH 1? i4 4<<ft.1\.
~NTH DAY I~R
D.
E.
13. A. AGE 19
14. EMPLOYMENT
A. USUAL OCCUPATION UnemplQ,Ved
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Bronx New YorIc
(CITY, ST1.TElCOUNTRY IF NOT USA)
16. FATHER
A. NAME \NAIter AdAcin
B. COUNTRY OF BIRT..tJ S A
17. MOTHER
A. MAIDEN NAME l<atbIeen Ann Santiago
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
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B. 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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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29. OFFICIANT
NAME (PRINT)
SPECIFY Ll )g pH a r-
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