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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MEO AntoniOM~tpncn
\"
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutch..
. CllyrrOWN Wappinger
DI::;TRICT
N~MBER 1368
~5~I~J~R71
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME ~n!UI Maribel Valenzuela
FIRST MIDDLE
CURRENT SURNAME
11. A.
CURRENT SURNAME
ll.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Valenzuela-VlV8nco
(OPTIONAL - SEE REVERSE)11U:: D"'-~19
D. SDCIALSECURITYNUMBER -~
12. RESIDENCEA.......,vork B. Dutchess
~) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND We .
SPECIFY DDlnaer
D. STREET ADDRESS17 pye Lane
ZIP 12590
o YES~ NO
1mO
YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEl.u....
D. SDCIALSECURITYNUMBER W/-76-7~
2. RESIDENCE A. ~,y;0It B. ~
C. CHECK ONE 0 CITY e TOWN 0 VILLAGE
AND Wa .
SPECIFY ppnpr
D. STREET ADDRESS 17 PyA LAnA ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 71 3B. DATE OF BIRTH .. - ft. / N.l /4ORA
~
4. EMPLOYMENT
A. USUAL OCCUPATION Accoi,rwtant
8. TYPE OF INDUSTRY OR BUSINESS OIlI'Al'ft Imn \AIrJrIs
5. PLACE OF BIRTH ~~~OT USA)
6. FATHER
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE34 13.B. DATE OF BIRTH 08 30
MONTH DA V
14. EMPLOYMENT
A. USUAL OCCUPATION Unempoved
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTHUm8. Peru
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Francisco Valenzuela
B. COUNTRY OF BIRTHPer'u
17. MOTHER
A. MAIDEN NAME TOfW?-a I-Ila...
B. COUNTRY OF BIRTHPeru
lB. NUMBER OF THIS MARRIAGE 2
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A. NAME AntonIo Vlvenrn
B. COUNTRY OF BIRTH Pen I
7. MOTHER
A. MAIDEN NAME Norm. C.rdIAII
B. COUNTRY OF BIRTH P<<u
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o
B. HOW DID LAST MARRIAGE END? (3) r!! DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? m / m / ?nn1
MONTH DAY YEAR
O. ARE ANY FORMER SPOUSE(S) ALIVE? i!!fvES 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
1 ST 03t02f20I't1 ~ PI.", N8N York
2ND 0
3RD 0
~H 0
I, being duly sworn, depose and say, that to the best of my knowledge an
as to my right to enter into the mar. 'age state. ()
21. SIGNATURE OF GROOM ~ COG\.
. SIGNATURE OF BRIDE ~
1
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 0 0
8. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT__~ fJ DEATH
C. DATE LAST MARRIAGE ENDED? 03 / 02 /2U01
MONT~ OAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? C! 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
1ST mmI2OO1 \NhIte Plains. New York ~
~
o
o
2ND
3RD
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23. SUBSCRIBED AND SWORN TO BEF RE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Stat
Relations Law ~11 to perform marriage ceremonies within
o If checked, this license is t
24. TOWN OR CITY CLERK
DATE
of the bride and groom named above by any person authorized by New York Domestic
W York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
e used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL}
'-..-'
YEAR
MONTH
YEAR
TIME
MONTH
NAME (PRINT)
DATE CJ112.512f.X)5
12590
TATE
27. TYPE OF CEREMONY
1~
AM ff1
03:05 PM
26
2005
09
23 2005
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ...efTOWN OF 0 VILLAGE OF
SPECIFY ~f} ff I ~ r
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
OTHER, SPECIFY
29. OFFICIANT ~~~ m' I'"V'O.
:=~::::~I .. . tf.M:;J - :: -J/:tl!?CF
~~NG A~~ le/au M < ~I ~ B 0Y I.)..~O
C>STREET CITYrrOWN J V . I STATA: ZIP
30. WITNESS TO CEREMONY. 31. WITNESS TO CEZMONY
NAME (PRINT) ':J) CV\ 'I t \ Le U..J\ t" NAME (PRINT) I () If
SIGNATURE~ ~(A~ \U \.J \. 1 r-- =-- SIGNATURE~
DOH-98 (11/98)