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COUNTY Dutchess
CITYfTOWN Wappinger
~~J:~C: . 1368
. ~5~I~J~R 140
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Armando ~iar
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
laura L Mosca
MIDDLE CURRENT SURNAME
.-J
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
8. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 584-86-7303
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. Nm York B. n~~
(ST A ) (COUN )
C. CHECK ONE 0 CITY []Il"rOWN 0 VILLAGE
AND Wa'
SPECIFY pp1nger
o STREET ADDRESS 10 L Scenic Drive
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c. SURNAME AFTER MARRIAGE Agt liar
(OPTIONAL - SEE REVERSE) on ~A A869
D. SOCIAL SECURITY NUMBER - -~-
12. RESIDENCEA. New York B. DlJt~
(STATE) (C~
c. CHECK ONE 0 CITY Olllll'owN 0 VILLAGE
AND Wa'
SPECIFY pplnger
D. STREET ADDRESS 10 L Scenic Drtve
ZIP 12590
YES D"NO
/1~
ZIP 12590
o YES ~NO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE 44 13.B. DATE OF BIRTH ~~ / t~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 4R 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Corrections Officer
B. TYPE OF INDUSTRY OR BUSINESS Flshklll Corr. FAcility
5. PLACE OF BIRTH ~~tbNT~O~~
6. FATHER
A. NAME Victor Aguiar
B. COUNTRY OF BIRTH Pu!lM'to Rloo
14. EMPLOYMENT
A. USUAL OCCUPATION Depsrtment Secretary
B. TYPE OF INDUSTRY OR BUSINESS VAC.C.Af BrM MII!Id ctr
15. PLACE OF BIRTH Manhattan New York
(CITY, STATElCOUNT~Y IF NOT USA)
16. FATHER
A. NAME Peter GOn2Jllez
B. COUNTRY OF BIRTH PtJ8rto RIM
17. MOTHER
A. MAIDEN NAME Helen sat.
B. COUNTRY OF BIRTH I J S A
18. NUMBER OF THIS MARRIAGE ~
7. MOTHER
A. MAIDEN NAME Lorenza Lopez
B. COUNTRY OF BIRTH PUArto RIM
8. NUMBER OF THIS MARRIAGE 4
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
3 0
B. HOW DID LAST MARRIAGE END? (3) cMjlVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 10/ 01 / 2004
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? OIllfES 0 NO
1 D. 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
08I12/1f188 BI~iM, N V
01109/1989 MonticellD, NY
1010112004 Sullivan Coo"", N Y
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) O~VORCE (3) 0 ANNUUMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? O? / 15 / 1994
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? o-fEs 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUEO AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o 1ST Q2/1511~1 ~~. ~York 0" 0
~ 2ND 0 0
o 3RD 0 0
o 4TH 0 0
belief that the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ A- / I'd hi p (!.CJ--
~USECURR~E
DATE 10127/2004
This license authorizes the marriage in New York S te of the bride and groom named above by any person authorized by New York Domestic
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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DEATH
DEATH
o
o
1ST
2ND
3RD
4TH
I, being duly sworn, depose and
as to my right to enter into the
0"
o
0"
21. SIGNATURE OF GROOM
~
{ SEAL}
'-.,,-'
10
NAME (PRINT)
YEAR
TIME
MONTH
AM
ZIP 03:04'M
1~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME A
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY rPa7C~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./'
o CITY OF 0 TOWN OF ~LLAGE 0;..... J J..
SPECIFY /"A.J~/iCiJtlOJ ~
SIGNATURE ~ -
DOH-98 (11/98)