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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
G~~?n Hem~e~~~~ HAyes CURRENT SURNAME
:>11411: riLl: nUMDI;;F'1
(THIS SPACE FOR STA TE USE ONL Y)
COUNr{)utchp-s~
CITYiTOWNWappingp-r
~~~~kC~136a
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B BIRTH NAME, IF DIFFERENT
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME Maria Esther Scala
FIRST MIDDLE
B BIRTH NAME (MAIDEN NAME), IF DIFFERENTPabon
c. SURNAME AFTER MARRIAGE Hayes
(OPTIONAL - SEE REVERSEloI 01 56-3018
D. SOCIAL SECURITY NUMBER . I -
12. RESIDENCE ANew York B. Dutchess
(STATE) oL (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN [J VILLAGE
~~~ClFyWap~ingers Falls
D. STREET ADDRESS B High Street
~
CURRENT SURNAME
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE\.
D SOCIAL SECURITY NUMBER ",1 ~~gR?9
2. RESIDENCE A. NE1WA4~rsey B M~~~)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND M -PI-
SPECIFY OIT'~ Aln~
D STREET ADDREss48 Stockton Court ZIP 01950
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES"tJ NO
nR /04 /1960
M~NiH DAY YEAR
12590
ZIP
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E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES QNO
13. A. AGE31 13.8. DATE OF BIRTH 11 P4 1~tl
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Administrative Assistant
B. TYPE OF INDUSTRY OR BUSINESS polymedCo InC_
15 PLACE OF BIRTHManhattan, New York
(CITY, STATE/COUNTRY IF NOT USA)
3. A. AGE45
38. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION fIIIAnRgement Consultant
8. TYPE OF INDUSTRY OR BUSINESS Gemini Consulting
5. PLACE OF BIRTHI ft!i: Arweles~ California
(CITY, STA COUNT IF NOT USA)
6. FATHER
16. FATHER
A. NAMEAnqel Luis Pabon
B. COUNTRY OF BIRTrPuerto RICO
17. MOTHER
A. MAIDEN NAME Antonia Quinones
B. COUNTRY OF BIRT~uerto Rico
1 B. NUMBER OF THIS MARRIAGE 2
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A. NAME Gordon RAIJmAn HAYP-S
B. COUNTRY OF BIRTH I J ~ A
7. MOTHER
A. MAIDEN NAME Virginia Jean l-4i!i:nAY
8. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
DEATH
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D~TH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI,ORCE CIVIL ANfiULMENT
"
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? 13) 0 DIV0'l:16 (3) ~'1NULMENT20~~ DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? / /
MONTH 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
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRYNIF NOT I,!~A)rk SELF SPOUSE
o 0 1ST 06/21/2005 poughkeepsie, ew YO D' 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
ledge and belief that the information I provided is true .' no legal impediment exists
22. SIGNATURE OF BRIDE~' ~.i
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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 mart'
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11/30/2005
DATE
by New York Domestic
21. SIGNATURE OF GROOM
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23. SUBSCRIBED AND SWORN
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marri ge in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marnage 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) John C Masterson
C
01
29 2006
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{ SEAL }
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TIME
MONTH
YEAR
MONTH
YEAR
DATE 11/30/2005
er Falls NY 12590
OWN STATE
27. TYPE OF CEREMONY
AM
04:54PM
12
01
2005
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNTY ~\~!
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY Wo.~)(t,,~Q.\
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
11ll CIVIL
29. OFFICIANT
NAME (PRINT)
(,~ ~ \2 '2."\ OS
HON. JAMES D. PAGONES
TITLE