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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
Mich:l~~E GROOM
Dutchess
COUNTY VVa~l~
C1TYfWrt388
DISTRICT
~~:~~R 114
NUMBER
1. A. FUll NAME
FIRST
MIDDLE
CURRENT SURNAME
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B. BIRTH NAME, IF DIFFERENT
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C SURNAME AFTER MARRIAGE
. (OPTIONAL - SEE REVERSE083-52-11 08
D. SDCIAl SE~Lf&tc uuteneSS
2. RESIDENCE A. (STATE) ", B. (COUNTY)
C. X~5CK 01\laPilrijiri Fa 0 VilLAGE
SPECIFY 2587 South Aiehtle 12580
D. STREET ADDRESS Z~
E. IS RE~CE WITHIN LIMITS OF CITY OR INCORPORATED~GE? 280
3. A. AGE 3B. DATE OF BIRTH ~
MONTH DAY
4. EMPLOYMENT Manager
A. USUAL OCCUPATION C. C. S. I Lab&
B. TYPE OF IND~.ca BlrJiw.eaS.. ~
DrunA IWW 19(~
5. PLACE OF BIRTH t
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER JoaqIin Colon, Jr.
A. NAME Puerto Rico
B. COUNTRY OF BIRTH
Y~
YEAR
7. MOTHER Rafaele Santiago
A. MAIDEN NAME Puerto Rico
B. COUNTRY OF BIRTH 1
B. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVUCE CIVIL A1fLMENT
D't)TH
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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), e&fBi'iNT
C SURNAME AFTER MARRIAGE
. (OPTIONAL - SEE REVERSE074-74-8733
D. SOCIAL S~'Brk UUtCneSS
12. RESIDENCE A. (STATE) ", B. (COUNTY)
C. X~5CKCVVa~Cf. 0 VillAGE
SPECIFY 2587 Svutt. Avenue 12590
D. STREET ADDRESS Z.I>>
E. IS RE!1NCE WITHIN LIMITS OF CITY OR INCORPORAmVllLAGE~ 0 1J74 NO
13. A. AGE 13.B. DATE OF BIRTH --
MONTH DAY YEAR
14. EMPLOYMENT
Administnllion
A. USUAL OCCUPATION ctRKblI Engll.erI~
B. TYPE OF IND~ "Yut~
15. PLACE OF BIRTH t
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER Rocco Frank PedBtella
A. NAME USA
B. COUNTRY OF BIRTH
17. MOTHER N8~ Michele D' Arnie!
A. MAIDEN NAME U 6 A
B. COUNTRY OF BIRTH 1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DtfRCE CIVIL A~ULMENT
D'OTH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE 13) 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
2 . SIGNATURE OF BRIDE ~
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o 1ST
o 2ND
o 3RD
o 4TH
belief that the information I provided is t
23. SUBSCRIBED AND SWORN EFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Sta
Relations Law ~ 11 to perform marriage ceremonies within
o If checked. this license is t
~ 24. TOWN OR c3OI1n~. Masterson
{ } NAME (PRINT) -fl:2:::.
~ ~~~~_tN'=~
STREET CITY !TOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER- -f
SONS NAMED ABOVE ON THE 0 III RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 05 9 0 OTHER, SPECIFY
of the bride and groom named above by any person authorized
ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
be used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
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29. OFFICIANT
NAME (PRINT)
TITLE
DATE
DATE
by New York Domestic
TIME
MONTH
YEAR
1-38 AM 09
- PM
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY -:iJJrtJlIfli
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VilLAGE OF
SPECIFY ilJJ/jfJt/~~ .
/~j/6'
STATE