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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
David Sandoval
MIDDLE CURRENT SURNAME
Saldoval
COUNTY Dutchess
CITYrTOWN WapPInger
~~~~lfii 1368
~~~I~J~R 9
1. A. FUll NAME
FIRST
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1212 lC:D3562
D. SOCIAL SECURITY NUMBER -~~--
2. RESIDENCE A. New York B. Dutchess
(Si'ATE) . (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILlAGE
~~CIFY Wappingers Falls
D. STREET ADDRESS 6304 Princess CIrcle ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?' r!!! YES 0 NO
3. A. AGE :.S 3B. DATE OF BIRTH O? /01 /1Q70
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Alcohol Counselor
B. TYPE OF INDUSTRY OR BUSINESS st. Francis Has.pltal
5. PLACE OF BIRTH ~!~~~&U~~N~~~
6. FATHER
A. NAME Genaro Sandoval
B. COUNTRY OF BIRTH Puerto Rico
7. MOTHER
A. MAIDEN NAME Migdalis Odiz
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
YEAR
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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 ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Lori E. Marable
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Marable. Sandoval
(OPTIONAL - SEE REVERSE) 112 lC:C1792
D. SOCIAL SECURITY NUMBER - - - .~---
12. RESIDENCE A. N~Ttork B D~~
C. CHECK ONE 0 CITY 0 TOWN I!! VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 6304 Princess CIrcle ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
os /10 ,;(QR1
MONTH DAY YEAR
13. A. AGE 4:'
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Executive Assistant
B. TYPE OF INDUSTRY OR BUSINESS Phoenix Programs Of N Y
15. PLACE OF BIRTH Peeksldll. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Thomas Marable
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Yvonne Worthy
B. COUNTRY OF BIRTH U ~ A
18. 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
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
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
YEAR
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o 1ST
o 2ND
o 3RD
o 4TH
nd belief that the information I provided is true a
o 0
o 0
o 0
o 0
that I declare that no legal impediment exists
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St e of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies withi 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
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{ SEAL }
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NAME (PRINT)
E, ?J1tL(o.JJ
22. SIGNATURE OF BRIDE ~ .'
USE CURRENT NAME
DATE o?/OQl?OO5
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
ZIP
AM
01:54 PM 02
10
04
10 2005
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TYPE OF CEREMONY
o ~ELlGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED...... L I _
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
o CITY OF 0 TOWN OF ~ILLAGE OF
I &fJS fIYl
29. OFFICIANT
NAME (PRINT)
SPECIFY