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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
-,
--1
0-
N
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
1. A. FUUNAME AnnAl Ramol 11. A. FULL NAME Blanche Cuevas
~ MIDDLE CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME). IF DIFFERENTCuevas Santiaao, Blanche
c. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE Cuevas:.R"am os
(OPTIONAL. SEE REVERSE). (OPTIONAL. SEE REVERSEn82-46-0546
D. SOCIAL SECURITY NUMBER u74 44 8887 O. SOCIAL SECURITY NUMBER U
2 RESIDENCE A NV B nllt~hp-~~ 12. RESIDENCE ANY . B.Dutchess
. . I (STATE) . ~NlV) (STATE) (COUNTY)
C. CHECK ONE 0 CITY'llJ TOWN 0 VILLAGE C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE '
AND W" .. AND \A1ann".naer
SPECIFY applnger SPECIFYW~ ,..,.. .
D. STREET ADDREss3RF Winthrop ct Apt E ZIP 12590 D. STREET ADDRES~8E Winthrop ct Apt E
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIUAGE? 0 YES"tJ NO E: IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGF48 38. DATE OF BIRTH a /O?AY /1~~l 13. A. AGF51 13.B. DATE OF BIRTH O~ONTH ~ DAY
4. EMPLOYMENT 14. EMPLOYMENT
A. USUAL OCCUPATION CablE! Techni~iAn A. USUAL OCCUPATIONAssistant Principal
B. TYPE OF INDUSTRY OR BUSINESS Time Warner Cable 8. TYPE OF INDUSTRY OR BUSINESSPsms 20
5 PLACE OF BIRTHManhs:athm N V 15. PLACE OF BIRTHPunta Santiago, Puerto Rico
. n (crrv:':!W~'cOUJ\lTRY IF NOT USA) (CITY, STATE/COUNTRY IF NOT USA)
6. FATHER 16. FATHER
A. NAME Angel Mario Ralllos A. NAMEPedro Cuevas Cuevas
B. COUNTRY OF BIRTH PuP-rio Rir.o B. COUNTRY OF BIRT"puerto Rico
7. MOTHER 17. MOTHER
A. MAIDEN NAME Camaen Rivera A. MAIDEN NAME Blanca Santiapo Berrios
B. COUNTRY OF BIRTH Puertn Rir.n B. COUNTRY OF BIRT"puerto Rico
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
DIVORCE CIVIL ANNULMENT DEATH DIVORCE. CIVIL ANNULMENT DEATH
') 0 0 1 0 1
B. HOW DID LAST MARRIAGE END? (3)!l DIVORCE (3) 0 ANNULMENT (2) 0 DEATH . 8. HOW DID LAST MAElR1AGE END? (3) ~ DIVORCE (3) 0 ANNULMENT 0) 0 DEATH
C. DATE LAST MARRIAGE ENDED? OS / 22 /2002 c. DATE LAST MARRIAGE ENDED? 04 / 04 /20 2
~ ~ ~ - ~~ ~ ~
D. ARE ANY FORMER Sf'OUSE(S) ALIVE? r~tYES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNWLED, PROYIDE THE FOLLOWING INFORMATION 2a. 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/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 051-22/2002 Sno"omi~h ~n ,bhtJUrgtnn r:1 0 1ST 04104/2002 Bronx. NY 0 ~
2ND ".. "" " 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
J, being duly SWDrn, depDse and S , of my knowledge and belief that the infDrmation I provided is tru, legal impediment exists
as to my right to enter into the m ria
ZIP 12590
DYES"'b NO
1954
YEAR
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21. SIGNATURE OF GROOM ~
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23. SUBSCRIBED ANO SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Stat of the bride and groom named above y any person authorized
Relations Law 911 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
DATE
by New York Domestic
~
{ SEAL }
'-v-I
NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
DATE 11/0212005
NY 12590
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
06:44 ~~ 11
03
2005
01
01 2006
ZIP
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND ''') I sri .'. t'
PLACE INDICATED. ^ . . PM j. 10 ()..::>
./ ~r;. .~ ~ ..d.-.r' C.
29. OFFICIANT !J'~ ~ . I j -h> /l~ r^",=c" r Il~
NAME (PRINT) l..I;;-r;:;N ',I'-'77I1~!b ~6e ~tt/AJ(\ Uj';1.L!.{ if '^-ll
SIGNATURE ~ ~/ ;. . ., ~".~ DATE 2J;.:c I~ ,2O-r)~
MAILING AD ESS' I"'J h} Co. . I
:~,~,j/~ I"Z-. WI fO/NC..bt€S rflLl-$, A ,/'1. /.2 .
CITYrrOWN STATE
((.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. couNrkltl~
~CIVIL
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~N OF 0 VILLAGE OF
SPECIFY a. ,//-~G~
SIGNATURE ~
DOH.98 (11/98)
SIGNATURE ~