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COUNTY J"lt ..~
CITYfTOWN Wapplng8f
DISTRICT 1388
NUMBER
~~~~J~R 33
STATE OF NEW V'ORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MPolJ d La Dll~JRRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
l8urie Fuentes
MIDDLE CURRENT SURNAME
~
1, A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
ll.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE I a Duca
(OPTIONAL. SEE REVERSEr"
D. SOCIAL SECURITY NUMBER 117.56-3293
12. RESIDENCEA. N~TXOrtc B. D~i
C. CHECK ONE 0 CITY ~TOWN 0 VILLAGE
AND r") bkee'
SPECIFY r oug paae
D. STREET ADDRESS 213 Tanglewood 011\1$ ZIP 12~-90
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES !if' NO
Mga /2jv -19ji
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 Q3..64-8065
2. RESIDENCE A. N~EY or:lc B. ~eii
C. ~~gCK ONE 0 CITY Iijf TOWN 0 VILLAGE
SPECIFY Poughkeepsie
D. STREET ADDRESS 28 Tan~ewoocI Dnve ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
MO~ / Qa
12590
YES ~ NO
/~
13. A. AGE 40
14. EMPLOYMENT
13.B. DATE OF BIRTH
3. A. AGE 39
4. EMPLOYMENT
3B. DATE OF BIRTH
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A. USUAL OCCUPATION Admini*1iItor
B. TYPE OF INDUSTRY OR BUSINESS Montefiore Hosp.
15. PLACE OF BIRTH q~f~X~SA)
16. FATHER
A. NAME Hany Fuentes
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Elba MartiAeZ
B. COUNTRY OF BIRTH Puerto Rloo
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A. USUAL OCCUPATION Service Technichilr:l
B. TYPE OF INDUSTRY OR BUSINESS V.nzon
5. PLACE OF BIRTH ~_~l~XSl~
6. FATHER
A. NAME Bernard Thomas La Duca
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Un. Lou Decker
B. COUNTRY OF BIRTH U $ .A.
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
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DEATH
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(2) 0 DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) r:VDIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 04 / n1 / ..aatl
MONTH oM ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? [jI'(ES 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
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DA V 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
1ST 04101/1M Carmel, NY 0 [ill' 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I, being duly sworn, depose and say, that to the best of my kn wledge and belief that the information I provided is tru
as to my right to enter into the marriage s~
21 SIGNATURE OF GROOM ~ ~ . SIGNATURE OF BRIDE
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE 05.'1Q/2005
This license authorizes the~rriage in New York Stat of the bride and groom named above by any person authorized by New York Domestic
Relations Law 911 to perform arriage ceremonies within W York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
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 25. B. ~~~~Mt,!Z~m~~.f~~D
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
MAILING ADDRESS '
'-v-I
YEAR
YEAR
MONTH
TIME
MONTH
AM
PM
08 2005
05
10
200
07
ZIP
. ATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS ~IVIL
OTHER, SPECIFY
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 4;(TOWN OF 0 VILLAGE OF
SPECIFY ~ IV 1" r
29. OFFICIANT
NAME (PRINT)
TREET
30. WITNESS TO CEREMONY
NAME (PRINT) Y
SIGNATURE ~
DOH-98 (11/98)
SIGNATURE ~