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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Miehael Haase
FIRST MIDDLE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) cfDIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 08 / 08 /2003
MONT~ DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ITYES 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 1ST OMJ8QOO3~!I..NY 0 ~
o 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
knowledge and belief t at the information I provided is true and that I declare that no legal impediment exists
{ldAfs({C/;i~1T N~lIltn/JA
DATE ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Stat of the bride and groom named above by any person authorized
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.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
n C. MIIII:enIon
COUNTY 0Utch---
CITY/TOWN \Nappinger
~~J~kc~ '1~
~5~~J~R A8
1. A. FULL NAME
CURRENT SURNAME
0-
N
8. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)218-"" ~"3I""
D. SOCIAL SECURITY NUMBER --~
2 RESIDENCEA. ~Vortc B. ~--
~~ (C~)
C. CHECK ONE 0 CITY ri! TOWN 0 VilLAGE
AND o-uooh~..
SPECIFY .---V~
D. STREET ADDRESS 4 C8Ud8 Lane ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES !If NO
3. A. AGE 41 3B. DATE OF BIRTH 04 /,0 /1GR4
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION ""~ans SeIge8nt
B. TYPE OF INDUSTRY OR BUSINESS SIng Sing Carr. Fee.
5. PLACE OF BIRTH Peelc!dclllNew Vade
(CITY, STATE/C~UNTRY IF NOT USA)
6. FATHER
A. NAME Rudalfl 1____
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Madenne Pug1IW1'"
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? DB / 28 / 2004
MONT~ DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? crYES 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
Mf28f2l1D4 DftI~.. N V r!/
DEATH
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and ,
as to my right to enter into the ma r a
21. SIGNATURE OF GROO
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{ } NAME (PRINT)
SEAL SIGNATURE ~
'-v-l MA~Gtifc
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL YI
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~~,ne S8nti~LE
11. A. FULL NAME
CURRENT SURNAME
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE l-...e
(OPTIONAL. SEE REVERSE)CI1" ..01969
D. SOCIAL SECURITY NUMBER ~--
12. RESIDENCEA. NlutVork B. Dutchess
~ (COUNTY)
C. CHECK ONE 0 CITY f!I TOWN 0 VilLAGE
- AND n-. ......____.;
SPECIFY r-UUWl~e
D. STREET ADDRESS 4 C8Ud8 Lane
ZIP 12603
DYES~NO
UiS8
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 3S 13.B. DATE OF BIRTH 12 m
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Correction onicer
B. TYPE OF INDUSTRY OR BUSINESS FIshIdII Corr. Fee.
15. PLACE OF BIRTH New yortc. New Vark
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Hectar Manuel SIInIi8go
B. COUNTRY OF BIRTH PIMrto Rico
17. MOTHER
A. MAIDEN NAME -=-..... A'*'
B. COUNTRY OF BIRTH PIMrtD Rico
18. NUMBER OF THIS MARRIAGE 2
DEATH
o
. SIGNATURE OF BRIDE ~
by New York Domestic
TIME
MONTH
DAY
YEAR
MONTH
YEAR
DATE 06I23I'2D05
11:32AM 06
PM
24
2005
08
22 2005
F811s NY 12590
WN TE
27. TYPE OF CEREMONY
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~~S5
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF Jt VILLAGE OF
SPECIFY W./l'p."o/Alc;.~/X ~S
~ RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVil
NAME (PRINT)
SIGNATURE~