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1. A. FUlL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Pedro Benito Ahril VR!i:QIJP.7
FIRST MIDDLE CURRENT SURNAME
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STAT!: f'ILt:. NUMat:"
(THIS SPACE FOR STATE USE ONL Y)
COUNTY Dutchess
CITYfTOWN Wappinger
~D'J~ifFi 1368
~5~\iJ~R 107
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME ~ A. Abril MIDDLE
CURRENT SURNAME
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B. BIRTH NAME, IF DIFFEREI'lT B. BIRTH NAME (MAIDEN NAME), IF DIFFEREI'lT
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE Abril
(OPTIONAL _ SEE REVERSE) (OPTIONAL - SEE REVERSE1
D. SOCIAL SECURITY NUMBER D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. N~WA~ ork B. ~!i:!t 12. RESIDENCE AN 'XSTATE) B. D'4!Gth.c
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE C. CHECK ONE 0 CITY i!I TOWN 0 VILLAGE
~~~CIFY Wappingers Falls ~~~CIFYW8pringer
D. STREET ADDRESS 76 East Main Street ZIP 12590 D. STREET ADDRES~418 ROlJtp. Q n z1P12~Qn
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIULAGE? "ll YES 0 NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES-t! NO
3. A. AGE':\ 3B. OATE OF BIRTH_~~H /2iy /1~p- 13. A. AG~6 13.B. DATE OF BIRTH OiNTH ~ DAY 19J~R
4. EMPLOYMENT 14. EMPLOYMENT
A. USUAL OCCUPATION Auto Mechanic A. USUAL OCCUPATIONHairdresser
B. TYPE OF INDUSTRY OR BUSINESS Performance Motorcars Inc B. TYPE OF INDUSTRY OR BUSINEssRnhp.rt!i: ~Rlnn
--S;--PtACE-OFBIRT~uenca.lEcuador~-------~--~-- -lDIACEOFBjRT~"enr.R rfflAifnr ----- --------
(CITY, STATE/COUNTRY IF NOT USA) (CITY, STAi!iCOUNTRY IF NOT USA)
6. FATHER 16. FATHER
A. NAME Julio Abril Oleas A. NAMElvan Ahril
B. COUNTRY OF BIRTH Ecuador B. COUNTRY OF BIR"nFr.IJRdor
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17. MOTHER
A. MAIDEN NAMEMercy Calle
B. COUNTRY OF BIRrJ=r.IJRdnr
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o n
7. MOTHER
A. MAIDEN NAME Gloria VasqUe7
B. COUNTRY OF BIRTH Ecuador
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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(2) 0 DEATH
DEATH
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(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMEI'lT
/ /
B. HOVl DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMEI'lT
/ /
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/COUI'lTRY, IF NOT USA) SELF SPOUSE
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
(MOI'lTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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21. SIGNATURE OF GROOM"
DATE 091n717005
by New York Domestic
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23. SUBSCRIBED AND SWORN TO BEFORE ME
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 perfor.m 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
{ } NAME (PRINT) Joh C M ste
TIME YEAR
SEAL SIGNATURE ~ .._.~_. DATdl9/0712005
'-- .-J M4ll.1~l,gDflEe. AM
-v- S~~ETMlaal stl'"Rd. Wappi~i~~alls. NYSTll590 ZIP 3:58 PM
~~~R~~R~~~ 10~O~~~N~ZE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS ;;(" CIVIL
DATE AND AT THE TIME AND /'1t:10'" 9 0 OTHER, SPECIFY
:~::~~:::::E~D J~'....,r:AJr ~M~ ' .c. ~ ."f". ..J/. <tal C.
NAME (PRINT) ~ ;;J. .... TITly'iJ'''O~ IfA;\lIv...k!sra .".-.o("'(
SIGNATURE ~ ' ?(fF~ ,,0t~ DATE t'~r. 29.. :McJ,tt)
MAILING Agpo78~ /'1 ;, /i/
II 1<:l!::[."'GR..i/t1t/l I~. J(/~~ ~.k4S IK i', a.r~
STREET CITYrrOWN STATE
30. WITNESS TO;J?E EMONY
'1ClLH"O DUt€nN
NAME (PRINT) '7 '\. .......,
H -!. an"") [JcJf2.6.f\.J
06 2005
MONTH
YEAR
1
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYOR/tttlGf.
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
K CITY OF 0 TOWN OF D VilLAGE OF
SPECIFY Nr ..iiJI'3!/f2,G1/
SIGNATURE ~
DOH-98 (11198)
SIGNATURE ~
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