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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Kenneth Domenick Fiore
Dutchess
COUN;; Wappinger
giiJ~gTWN., ~
~~~I~~~R 21
NUMBER
1. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 096-64-4645
D. SDCIAL SECURLTY NUMBf'l
2 RESIDENCE A. New york B. Dutchess
(STATE)., (COUNTY)
C. CHECK ONE W 0 CITY 0 TOWN 0 VILLAGE
AND applnger
SPECIFY 5 HAl""". Ol'l\1e 1~590
D. STREET ADDRESS.... ZIP
.,
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES 0 NO
3. A. AGE 28 3B. DATE OF BIRTH 05 / 18 / 197
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Sale8
B. TYPE OF INDUSTN OR lil..soa.s Canon .
5. PLACE OF BIRTH New t( elle, New YOrk
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Stephen Michael Fiore
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Oenlse Ann Boghosslan
B. COUNTRY OF BIRTH USA
,
B. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVOR8E CIVIL ANN'bMENT
DEATa
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Juliana Francis Cueva
-.J
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Fiore
(OPTIONAL - SEE REVERSE) 133-66-3480
D. SDCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STATE)" (COUNTY)
C. CHECK ONE\Al 0 .CITY 0 ,OWN 0 VILLAGE
~~~CIFY napplnger
D. STREET ADDRESS 6 H AlPIne onve
ZIP 12080
",
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES 0 NO
07 / 11 /1977
MONTH DAY YEAR
13. A. AGE 27
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAl OCCUPATION Physcial Therapist Assistant
B. TYPE OF INDUSTL\.Y O~I!YSJ~.E~S New VVlnasor P. T.
15. PLACE OF BIRTH t;jmnmown, New York
(CITY. STATEICOUNTRY IF NOT USA)
16. FATHER
A. NAME Mario Washington Cueva
B. COUNTRY OF BIRTH QUItO EcuadOr
17. MOTHER
A. MAIDEN NAME Carol Ann Orteae
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV08CE CIVIL ANNOMENT
DEATH
o
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
o
o
o
1ST 0 0 1ST
~ 0 0 ~
3RD 0 0 3RD
4TH 0 0 4TH
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is tr
as to my right to enter into the marriage state. ..
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK~ DATE
This license authorizes the marriage in New York St authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies withi 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 CLERt< 25. A. SOLEMNIZATION PERIOD BEGINS
Glons J. Morse
w
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{ } NAME (PRINT)
SEAL SIGNATURE ~ ,-
'-v-I MAI~ MiBebush R
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE ANO AT THE TIME AND
PLACE INDICATED.
TIME
MONTH
YEAR
-'DATE 03131
ger Falls, NY 12590
CITYfTOWN STATE
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
TIME MO. DAY YEAR 0 ~ RELIGIOUS
9 0 OTHER, SPECIFY
TITLE <~ ;'-l^-1-
DATE ....) - J b - ;::(' b~c-"
~~'1. )~
STATE
4(~'tl
29. OFFICIANT
NAME (PRINT)
ZIP
AM
12:01>M
04
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN;W,'n-V-<"
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VILLAGE OF
SPECIFY W l. f fJ' ~ '0 ~ v~ iF tUA.; ~
NAME (PRINT)
SIGNATURE ~