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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Gabriel X. Rivera
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
COUNTY Dutchess
CITYiTOWf w.PPngef
DIST!}ICT 368
NUM"ER
REGISTER 97
NUMBER
L 0 SUPPLEMENTAL FILE
Ageliki 1R~JHE BRIDE
11. A. FULL NAME
FIRST MIDDLE
CURRENT SURNAME
MIDDLE
CURRENT SURNAME
FIRST
B. BIRTH NAME (MAIDEN NAME), ~MT
C. SURNAME AFTER MARRIAGE 05~oe.AI:
(OPTIONAL - SEE REVERSE) ..,., -r>;JL;:TJ
D. SOCIAL SE~'8fk: Oub.:he55
12. RESIDENCE A. B.
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B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)Oft.~70-6735
D SOCIAL SEC~'Snc UlItChes5
2. RESIDENCE A. (STATE)" B. (COUNTY)
C X~6CK ONWapJi~ TOWN 0 VI~GE
SPECIFY 2 Pye Lane
D. STREET ADDRESS ZIP
E. IS RE~CE WITHIN LIMITS OF CITY OR INCORPORATED (tfGE? 2tf
3. A. AGE 3B. DATE OF BIRTH /
MONTH DAY
~NO
YEAR
12533
12596
01
Y/~9f6
YEAR
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4. EMPLOYMENT
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A USUAL OCCUPATION Cor1badu(~ R~
B. TYPE OF INDU~E!Y QEl_BJoWItIE!i.'lt___ - . k
mOnxvllle 1'ftJW' or
5. PLACE OF BIRTH ·
(CITY. STATEICOUNTRY IF NOT USA)
6. FATHER Dennis Rivera
A NAME p..-to Rlw
8. COUNTRY OF BIRTH
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17. MOTHER Aspesla Roupe
A. MAIDEN NAME G~
B. COUNTRY OF BIRTH 1
1 B. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI'Q'RCE CIVIL A'lfLMENT
7. MOTHER Marla M. Narvaez
A. MAIDEN NAME
8. COUNTRY OF BIRTH ~ RICO
B. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVCOCE CIVil ANtylMENT
DE'(fH
DEtJH
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
2D. 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
C. DATE LAST MARRIAGE ENDED?
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
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at to the best of my knowledge and belief that the informatIOn I provided is true and that I declare th~gal Impediment eXists
estate. ~' .--, tJ~
21. SIGNATURE OF GROOM ~ ' 22 IGNATURE OF BRIDE ~
23. SUBSCRIBED AND SWORN TO BE ORE ME USE CURRENT NAME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York Stat of the bride and groom named above by any person authorized by New York Domestic
Relations Law !}11 to perform marriage ceremonies within w 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 CI"36t'1W't. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (P~INT) ~ ;lUQ5
SEAL SIGNATURE~ r~ ~ ll~l ~
'-.,;-I MA28>. C(Vi1ippl~alIS. NT 12590
STREET CITYfTOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER- - ./
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~ RELIGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. ,: 3~ q .- t Y - 05 90 OTHER, SPECIFY
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say
as to my right to enter into the marri
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YEAR
2B. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY ORA'" ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ITY OF 0 TOWN OF 0
VILLAGE OF
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