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CO"~~~~ST A ~~R?~N~o~~tX?RK
CITYfTOWN Wappinger
j~~~~Cri1368 AFFIDAVIT, LICENSE and
~G~~J~R136 CERTIFICATE OF
, l MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
#Gvt:",(. USE/:>
~€~ ~it:J€ (~~/o(,)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
A. FULL NAME
Omsr R()drig'JP.7
FIRST MIDDLE
11. A. FULL NAME QuimRna luz MIDDLE
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Quintana
C SURNAME AFTER MARRIAGE R~:~
(OPTIONAL SEE REVER~ ::_
D. SDCIAL SECURITY NUMBER FOU17
12. RESIDENCEANewrXerk BDt.f:_S
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
AND
SPECIFYf)eacon
D STREETADDREss125 Catherine street Z1P12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0(] YES 0 NO
13. A. AGI=44 13.8. DATE OF BIRTH ~n m ~961
I\mNTH DA Y ~EAR
14. EMPLOYMENT
A. USUAL OCCUPATIONPacking
8. TYPE OF INDUSTRY OR BUSINESSG h Ford Tea Co
15. PLACE OF BIRTi-PuertO Rico
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A NAMEFdIJvigis Quintana
8. COUNTRY OF BIRTPuerto Rico
CURRENT SURNAME
CURRENT SURNAME
0-
N
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SDCIAL SECURITY NUMBER
2. RESIDENCE A. N.A~ oric B. (COUNTY)
C. CHECK ONE 0 CITY'I4!J TOWN 0 VILLAGE
~~~CIFY Middletown
D STREET ADDRESS 1 05 Linden Avenue ZIP 10940
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YESo(] NO
3 A. AGE29 38. DATE OF BIRTH MUt /2~t /1~I6
4. EMPLOYMENT
A. USUAL OCCUPATION C"-OnstnlCtion
8. TYPE OF INDUSTRY OR BUSINESS
5. 'PLACE OF BIRTJ-tuamantla.. llaxcala, Mexico
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Mario Rodriguez
8. COUNTRY OF BIRTH Mexico
7. MOTHER
A. MAIDEN NAME c.:anru~n V~Ip.nI~ia
B. COUNTRY OF BIRTH Mexico
B. NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
UJ
I-
'"
l-
V)
17. MOTHER
A. MAIDEN NAME.llllia .Jimene7
8. COUNTRY OF BIRTPuerto Rir.o
lB. NUMBER OF THIS MARRIAGE 2
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
c. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
8. HOW DID LAST MARRIAGE END? (3) '1'5 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 12 / 13 /2002
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ 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
1ST 12/13/2002 Dutchess Co New Vortc 1'!1 0
2ND 0 0
3RD 0 0
o 0
no legal impediment exists
1:) ~
I
DEATH
o
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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to th
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM.
o
o
o
w
en
z
w
o
::::i
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK.
This license authorizes the marriage in New York Sta e 01 the bride and groom named above by any person authorized
Relations LaY,';Wk}ferlorm marriage ceremonies within New York State, THIS LICENSE VALID IN NEW YORK STATE ONLY.
.' -j , t .D II checked, thiS license IS to be used only lor the purpose 01 a second or subsequent ceremony,
~ 24. TOWN OR pITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
f. } NAME (PRINT) John C. Masterson TIME MONTH YEAR
SEAL SIGNATURE. DATE 1110212005
, MAlU.N~ ilDpt;l.FS~. AM 11 03 2005
~. _~~~TMKJaleDUsh Rd, Wappl~~r!aUS, NYSTJt590 ZIP :55 PM
I CERTIFY,JHAT,I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MAR.F!U\GE Or TflE PER-
SONS NAMED ABOVE ON"rHE TIME MO. DAY YEAR 0 0 RELIGIOUS
DATE AND AT THE. TIME..A~D.
PLACE INDICATED. , ~ f.:
01 2006
DATE
by New York Domestic
MONTH
YEAR
01
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK 8. COUNTY
29. OFFICIANT
NAME (PRINT)
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
TITLE
o CITY OF 0 TOWN OF 0 VILLAGE OF
SIGNATURE.
MAILING ADDRESS
DATE
SPECIFY
STREET
30. WITNESS TO CEREMONY
CITYfTOWN
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE.
DOH-9B (llI9B)
NAME (PRINT)
SIGNATURE.