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~ I ArE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MifW~1 Falcon
MIDDLE
23. SUBSCRIBED AND SWORN TO BEF E M
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State f 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.
D 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) oh C Masterson
09109/2005 TIME
SIGNATURE ~ DATE
MA20GMiddl; ushRd. Wappinaer Falls, NY 12590 09:25 ~~
STREET CITYITOWN STATE ZIP
~~~R~~~Ri~~~ 10~O~~~N~E~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ~ CIVIL
SONS NAMED ABOVE ON THE TIME MO. AY YEAR 0 D RELIGIOUS 1A:J\
DATE AND AT THE TIME AND / , 1.I"l
PLACE INDICATED. (t)' I tV PM I /~./ t:J-5" 9 D OTHER, SPECIFY
~~~ti~~~T.~00'J ~ ~/c$JE m" Ih~ ~~:"<r":{~
SIGNATURE ...(/~~ DATE !;YiE,-t'f:5Il1,vt::I(..J / ,
M~ll,l~ ADDfll; S 10 / J - AI f /
/ 11,\j5;;~RVO/te {.Iv. /lJft(JPflt/(yElS mW IV.. '1, /::J.59{)
STREET CITYITOWN
30. WITNESS TO CEf)fONY
NAME (PRINT) ~~.
couNnOutr-hp.~~
CITYlTowNWsppingar
~~J~~c;;r1368
~5~~J~R113
1. A. FULL NAME
CURRENT SURNAME
l"-
N
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERS~
D. SOCIAL SECURITY NUMBER u81-R4-~145.
2 RESIDENCE A. NeMfAX)ort B. n~!t~~ss
C. CHECK ONE D CITY D TOWN totJ VILLAGE
~~~CIFY WRppingp.r~ Falls
D. STREET ADDREss6316 Princess Circle ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ofJ YES D NO
3. A. AGF4Q 3B. DATE OF BIRTH n..t. /14 /1Q5.~
MONIH DAY YEAR
W
I-
..
I-
en
4. EMPLOYMENT
A. USUAL OCCUPATION I sndscaping
8. TYPE OF INDUSTRY OR BUSINESS Self-employed
5. PLACE OF BIRTHMarti Cuba
(CITY, ?rATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Angp.1 Miguel Falcon
B. COUNTRY OF BIRTH Cuba
7. MOTHER
A. MAIDEN NAME Ofelia FlmdnrR
B. COUNTRY OF BIRTH C:uba
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 1 0 / 27 / 1998
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? M YES D 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
1n/:n/1QQR De Marti, Cuba c1 D
D D
D D
DEATH
o
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en
z
W
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~
{ SEAL }
'-v-I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
11. A.
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME Theodora Jean-ne From
FIRST MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE From - Falcon
(OPTIONAL. SEE REVERSE057-40-1487
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANew York BDutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
ANDn hk .
SPECIF~OUQ ee~sle
D STREET ADDRESs4:03 Sheafe Road
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE56 13.8. DATE OF BIRTH 09 04
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATIONMassage Therapist
B. TYPE OF INDUSTRY OR BUSINESSSelf-employed
15. PLACE OF BIRTEoughkeepsie, New York
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Theodore Stanley From
8. COUNTRY OF BIRTJJ S A
17. MOTHER
A. MAIDEN NAME Grace Simpson Touponse
8. COUNTRY OF BIRTM S A
18. NUMBER OF THill MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
ZIP 1 il~YU
.,
OYEsDNO
1949
DAY YEAR
DlfH
8. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
2ND
3RD
D D
D D
D D
D D
at I declare that no legal impediment exists
by New York Domestic
MONTH
YEAR
MONTH
YEAR
09
10
2005
11
08 2005
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY J)(,lTC)-jt:-st:.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF j;X TOWN OF D VILLAGE OF
SPECIFY f6'~J=(;::P:,.f:E
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) J:.cJ:;e~1j:J
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