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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.Iavier Vega
FIRST MIDDLE
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
h1~~SECJ~TN~
DATE 0712012005
COUNTY O. dche~s
CITYiTOWN Wappingp.r
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1 . A. FULL NAME
CURRENT SURNAME
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Maria Victoria Alonzo
FIRST MIDDLE
~
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 138-84-2634
D. SOCIAL SECURITY NUMBER - ------
2 RESIDENCE A. N Y B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY rrt ,TOWN 0 VILLAGE
AND W .
SPECIFY applnger
o STREET ADDRESS 13 H Alpine Drive ZIP 12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
"6 /2R /1911\
MONTH DAY YEAR
3. A. AGE 29
3B. DATE OF BIRTH
11. A. FULL NAME
CURRENT SURNAME
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4. EMPLOYMENT
A. USUAL OCCUPATION Software Engineer
B TYPE OF INDUSTRY OR BUSINESS IBM Corp
5. PLACE OF BIRTH Elmhurst". New York
(CITY, ST ATE/CuuNTRY IF NOT USA)
6. FATHER
A. NAME Jesus Vega
B. COUNTRY OF BIRTH Cuba
7. MOTHER
A MAIDEN NAME Lydia Rodriguez
B COUNTRY OF BIRTH Cuha
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
8. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE Alonzo
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 583-61-6534
12 RESIDENCE A. N Y B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 13 H Alpine Drive
ZIP 12590
DYES r1 NO
~14
YEAR
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 30 13.B. DATE OF BIRTH m~ Ai1
MONTH DAY
14, EMPLOYMENT
A. USUAL OCCUPATION Intern Architect
B. TYPE OF INDUSTRY OR BUSINESS L M V Architects
15. PLACE OF BIRTH Rio Piedras.. Puerto Rico
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Rogelio Alonzo
B. COUNTRY OF BIRTH S~nto Domingo, Dominican Republic
17. MOTHER
A. MAIDEN NAME Ysiniers Alerl'any
B COUNTRY OF BIRTH Santo Oomingo. Oominican Republic
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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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
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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23. SUBSCRIBED AND SWORN TO FORE ME
SIGNATURE OF TOWN OR CITY CLERK.
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform 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) Jo . a erson
TIME MONTH YEAR
SEAL SIGNATURE.' DATE 07/2012005
~ MAI~bGUidaiS ush Rd er Falls NY 12590 AM 07
STREET OWN STATE ZIP 06:03PM
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY ~
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED.
SIGNATURE.
DOH-98 (11/9B)
by New York Domestic
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
21. SIGNATURE OF GROOM.
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MONTH
YEAR
21
2005
09
18 2005
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF Ja:1OWN OF 0 VILLAGE OF
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SIGNATURE.