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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
J~Miguel Ft..Dles
COUNTY Dutchess
CITYfTOWN urappinger
DISTRICT ..
~~~I~~~R1368
NUMBER 11 S
1. A. FUll NAME
CURRENT SURNAME
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B BIRTH NAME, IF DIFFERENT
STATE FILE NUMBER ------
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
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C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 581-77-0835
2. RESIDENCE A NQWTY,ork B. D~33
C X~6CK ONE 0 CITY ~ TOWN 0 VILLAGE
SPECIFY Wappinger
D. STREET ADDRESS 1 Daniel Sabia Om. ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES oil NO
MD& /Z6v / W4
3. A. AGE31
4. EMPLOYMENT
3B. DATE OF BIRTH
11. A FULL NAME Da_Luz Tim_lDLE
CURRENT SURNAME
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A. USUAL OCCUPATION Factof')' \,A!erkcr
B. TYPE OF INDUSTRY OR BUSINESS Sol-Jlhes&t Container
5. PLACE OF BIRTH R!tv,Ps.m~RR~I.IRiGO
6. FATHER
A. NAME n/ a
B. COUNTRY OF BIRTH Puerto Rico
7. MOTHER
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE "'~r8Ies
(OPTIONAL. SEE REVER~'"
D. SOCIAL SECURITY NUMBER 076-68-.9595
B. Dijt.~s
~ TOWN 0 VILLAGE
12. RESIDENCE ANc'fAV~rk
C. CHECK ONE 0 CITY
AND
SPECIFYWappinger
O. STREET ADDREss1 Daniel Sabia Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
niNTH 26 DAY 19BtLR
13. A. AGE2S
14. EMPLOYMENT
13.B. DATE OF BIRTH
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A. MAIDEN NAME Nancy Moralc3
B. COUNTRY OF BIRTH Bayamon, Puerto Riso
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A. USUAL OCCUPATION Stucjent
B. TYPE OF INDUSTRY OR BUSINESS
15 PLACE OF BIRTH~~,MlII,t,lN,;tgrk
16. FATHER
A. NAME Jose Luis Tirade
B. COUNTRY OF BIRT"Puerto Rico
17. MOTHER
A MAIDEN NAME Moria Mildred Bonilla
B. COUNTRY OF BIRTi-U S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
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(2) 0 DEATH
100
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? n6 / 77 / "nn"
MONT~ 'trA'Y 4!,~1
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 0 0 0 ~
II: 2ND 0 0 0 0
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<D 3RD 0 0 0 0
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z I, being duly sworn, depose and say'
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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
23. SUBSCRIBED AND SWORN TO ORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State 0 the 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
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NAME (PRINT)
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
TITLE
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
DATE 09/15'2005
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
AM
PM
16
2005
11
09
14 2005
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURR~
A STATE NEW YORK B. COUNT~<<'R'~~.;;
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /'
o CITY OF 0 TOWN OF ia"'VILLAGE OF
SPECIFY U!I1fjqN€'€R.S /'ItUS
Rre. r,e16r
/~/~9 /0.)
1.200
31.
r
NAME (PRINT)
SIGNATURE ~