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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Fernando Pal8dos
FIRST MIDDLE
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutchess
CITY/TOWN \Napplnger
~:JJ:~c; 1388
~5~~J~R tIT
L D SUPPLEMENTAL FILE
CURRENT SURNAME
FROM THE BRIDE
11. A. FULL NAME XimeN:I Alexandnt AndnIde
FIRST MIDDLE CURRENT SURNAME
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N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE PRlMOS
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. t.III!!IAt Vark:
~
C. CHECK ONE 0 CITY ~ TOWN 0
AND 'Al- .
SPECIFY v".ppnger
STREET ADDRESS 208 All Angels HII Roed
B BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) -- .,,, -18
D. SOCIAL SECURITY NUMBER ~-""'-I~
2. RESIDENCEA. NewVark: B. n.~
(STATE) ~
C. CHECK ONE 0 CITY !I1t TOWN 0 VILLAGE
AND 'AI- .
SPECIFY vvappnger
D. STREET ADDRESS 208 All Angels HII Road ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
11 / 1~ /1Q.I\R
MONTH DAY YEAR
D.
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlLAGE?
13. A. AGE~ 13.B. DATE OF BIRTH OR ,(,Q
MONTH DAY
B.n.~
(COUNTY)
VILLAGE
ZIP 12590
o YES~ NO
~
YEAR
3. A. AGE 46
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Construction
B. TYPE OF INDUSTRY OR BUSINESS Self - Employed
5. PLACE OF BIRTH ECI.8dor
(CITY, STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION l..svvyer
B. TYPE OF INDUSTRY OR BUSINESS Human Rights In Ecuador
15. PLACE OF BIRTH QIJto
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME GLillenno Andrade
B. COUNTRY OF BIRTHQutto
17. MOTHER
A. MAIDEN NAME Bertha CIfuentM
B. COUNTRY OF BIRTHQuIto
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
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6. FATHER
A. NAME Luis Palacios
B. COUNTRY OF BIRTH ECU8dor
7. MOTHER
A. MAIDEN NAME Yolanda DfJI P^""
B. COUNTRY OF BIRTH Ecuador
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
1
(3) 0 ANNULMENT (2) r! DEATH
/ 1991
YEAR
B. HOW DID LAST MARRIAGE END? (3)[] 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
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THi:: FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED? 04 / 14
MONTH JAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES ~ 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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D. 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
owledge and belief that the information I provided is true)i!.
/"" .'
o 0
o 0
o 0
o 0
that no legal impediment exists
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23. SUBSCRIBED AND SWORN TO
SIGNATURE OF TOWN OR C CLERK ~
This license authorizes the marriage in New York State 0 the bride and groom named above by any person
Relations Law ~11 to perform marriage ceremonies within Ne ork 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(PRIN~) c. ~
{SEAL SIGNATURE ~ C DATE OBf12f2005
'-,-I M~lID Rd, ppinger Falls, NY 12590 12:20 ~~ 08
STREET CITY !TOWN ST A TE ZIP
~~~R~~~RT~~~ 10~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS tv"'CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
10
11 2005
by New York Domestic
YEAR
MONTH
YEAR
TIME
MONTH
13
2005
29. OFFICIANT
NAME (PRINT)
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF .l8('TOWN OF 0 VILLAGE OF
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