072
Dutchess
.. ;-OUNTY WlpplIyvi
CITYfTO~388
DISTRICT
NUMBER 12
REGISTER
NUMBER
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
M FROM THE GROOM
areo Antonio Jimenez
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
1. A. FULL NAME
FROM THE BRIDE
11. A. FULL NAME Ana Abril
FIRST
CURRENT SURNAME
MIDDLE
CURRENT SURNAME
MIDDLE
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT ~
C. SURNAME AFTER MARRIAGE .JmMC!!!l2'
(OPTIONAL. SEE REVERSE)~~ ~ '21-
D. SOCIAL SECURITY NUMBER ~~--~
12. RESIDENCEA.NewYork B.n.~
(ST~1E) ~
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
AND Pouah--l
SPECIFY MiIVUDIe
D. STREET ADDRES~ Rlnald BouIev8rd AP- 7k ZIP12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? .tJ YES 0 NO
13. A. AGr2.7 13.B. DATE OF BIRTH O~ -t.. ..-"JL
!!ONTH .&a DAY IIff~R
14. EMPLOYMENT
A. USUAL OCCUPATlorManager
B. TYPE OF INDUSTRY OR BUSINESsMc Donald!;
15. PLACE OF BIRT~~f., J:Naattto.r
~ST~UNTRY IF NOT USA)
16. FATHER
A. NAMJulio Abril
B. COUNTRY OF BIRTEcuador
17. MOTHER
A. MAIDEN NAM~ort8 V-<p IA7
B. COUNTRY OF BIR,Ecuador
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
. ~ 0
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE327-67-~
D. SOCIAL SE'NiWLf&1c Dutchess
2. RESIDENCE A. (SllIfPE) B. (COUNTY)
C, X~6CK ~~eOWN 0 VILLAGE
SPECIFY 56 ftlnaldI Soul IU
D. STREET ADDRESS evil Apt 7k ZIP 1~1
t IS R~NCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
3. A. AGE 3B. DATE OF BIRTH 01,/30 /1977
MONTH DAY YEAR
4. EMPLOYMENT SaI
esman
A. USUAL OCCUPATION R*rn AJj1J
B. TYPE OF INDti1tl ~Ei1elC1 an
5. PLACE OF BIRTH ,co
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER 1__ .Jmenez
A. NAME ~tudgg
B. COUNTRY OF BIRTH
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7. MOTHER Me rite M nt
A. MAIDEN NAME ~exlco 01 rano
B. COUNTRY OF BIRTH 1
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIQ>RCE CIVIL 1rULMENT
DEATH
DOATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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
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o 0 1ST 0 D
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
wledge and belief that the information I provided is true and that I declare that no legal impediment exists
~~~ 0rI\.. ~<, \ .
USE CUR~~ N~E
23. SUBSCRIBED AND SWORN TO BEFORE ME OAT rr'7'/27.'1"VVV:
SIGNATURE OF TOWN OR CITY CLERK ~ !WL......-~
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 ew 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.
{ ~ } ::~~~:~:;, J!I\ ~~ "A "'''"'''''"ON "''''' ""'"
SEAL A1i . ~.~~ . DA!l!..f012OO5 -
'-v-I d, Wappinger Falls, NY 12590
STREET CITYITOWN
~~~R~~~Ri~~~ IO~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED
SONS NAMED ABOVE ON THE TIME MO. 0 Y
~t~~E ~~gl'IT:~E TIME AND CJ C
1ST
2ND
3RD
4TH
I, being duly swqrn, depose and say, that to th
as to my right to enter into the marriage sta .
21. SIGNATURE OF GROOM ~
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YEAR
ZIP
29. OFFICIANT
NAME (PRINT)
STATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS 1 D J'IL NEW YORK "7). {.-rll~
~ A. STATE B. COUNTY..vV..LL~
9 0 OTHER, SPECIFY
LOCATION OF CEREMONY
~. ~ ". \ ~~ 17 ,I (CHECK ONE AND SPECIFY)
TIT~E/.l. ,fL. rIM.!.. ~ _t '-e J
ATE ~~.' ZZJ> ;(dj5 0 CITYOF,.g._T~WN,OF ~L"VILLAGEO~
, . SPECIFY<<.1'Tfi::>JA,/~ F~
,- ~1i / r /;2.:5'() )
STAT
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
ZIP
31. WITNESS TO m!/!k.Y
NAME (PRINT) } I If ~ft.J
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SIGNATURE ~