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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Donovan Crawford
:; I A I t: ~ILt: NUMlleR
(THIS SPACE FOR STATE USE ONL Y)
Dutchess
COUNTY WIIppI
CITYfTOWN nger
DISTRICT 1368
~~I~~~R S1
NUMBER
..J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
JacJvnn PadrD
FiRSt MIDDLE
DUPLICATE
ORIGINAL LOST
11. A. FULL NAME
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 087-68-2695
D. SOCIAL SECUGMtl~R
2. RESIDENCE A. r T ork . B. Dutchess
(STATE) ~ (COUNTY)
C. X~6CKONEpo..Qh~D TOWN 0 VILlAGE
SPECIFY ug psle
D. STREET ADDRESS 621 Sheafe Rosa LOl153 ZIP 12601
E. IS RESI~fE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES r1 NO
3. A. AGE 3B. DATE OF BIRTH 12 / 16 / 1980
MONTH DAY YEAR
B. BIRTH NAME jMAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Padro-CrAWfnm
(OPTIONAL - SEE REVERSE) 1
D. SOCIAL SECURITY NUMBER 22-72-~1 ~
12. RESIDENCE A. New v ork: B. n.drhess
(STAT~ ~)
C. CHECK ONE 0 CITY ofrOWN 0 VILLAGE
~~CIFY East Fishkill
D. STREET ADDRESS SO,Hosner Mountain Road ZIP 125~
· -. - Lot 3/
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES iY NO
13. A. AGE 20 13.B. DATE OF BIRTH ----19rH -iQAY ~R
14. EMPLOYMENT
A. USUAL OCCUPATION Dental Assimant
B. TYPE OF INDUSTRY OR BUSINESS Dr. Puma
15. PLACE OF BIRTH Carmel. Hew York
(CITY, STATE/COUNTRY IF NOT USA)
4. EMPLOYMENT
A. USUAL OCCUPATION
Unemployed
8. TYPE OF INDU~B&\SI~S
5. PLACE OF BIRTH · t!/IN Y OJ'I(
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER WI.
A. NAME lIam Crawford
8. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Hester \NhIte
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1V'tiCE CIVil AN~lMENT
16. FATHER
A. NAME Carlos G. Padro
B. COUNTRY OF BIRTH U S A
17. MOTHER
A. MAIDEN NAME BArnartll\& Made Gentile
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
DO
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
/ /
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
o 0
o 0
o 0
o 0
t no legal impediment exists
o
o
o
o
o
o
w
en
z
w
o
~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York S te of the bride and groom named above b any person authorized
Relations Law ~11 to perform marriage ceremonies with 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 C50~LEF~ Masterso 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) n. n
"""""mi"~ ~. ~ --.,. OA",lI6I27l2llD5
M2ltMRII Rd, ppinger Falls, NY 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 0 RELIGIOUS 1 IVll
DATE AND AT THE TIME AND A
PLACE INDICATEO.:1J1) 9 0 OTHER, SPECIFY
26 2005
DATE
by New York Domestic
~
{ SEAL }
~
YEAR
MONTH
YEAR
TIME
MONTH
AM 06
.26 PM
28
2005
08
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~,,1ZIft,.~
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
o CITY OF 0 TOWN OF I!l""VIllAGE OF
SPECIFY I1/fJdJP/~~ ~
SIGNATURE ~ .
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~