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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Flavia R~eA
MIDDLE ~ CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN WaDdnger
1368
139
D1STl'I\C;
NUMBER
REGISTER
NUMBER
1. A. FUll NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New
(Si'Ai'E)
C. CHECK ONE D CITY mOWN D VILLAGE
AND Wa.
SPECIFY pplnger
D. STREET ADDRESS 16 Brawn Road
ZIP Vl"'Jrr
DYES rYNO
122.R0.0504
B. gJ~
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E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE :I? 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Cook:
B. TYPE OF INDUSTRY OR BUSINESS Glnd~ TrAtMa
5. PLACE OF BIRTH Giron Canton
(CITY, STAlE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Manuel Elizandra R~eA
8. COUNlTRY OF BIRTH ECUAdor
7. MOTHER
A. MAIDEN NAME R~ BellncII Qt aMadl
B. COUNTRY OF BIRTH l;euaMr
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) D DEATH
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B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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 Pol C r'IL.c l"UMD~n
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Nwt! E. QUez_NT SURNAME
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11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), I F DIFFERENT
C. S~S~~m=rfR'~~~~~e~~SEI Reyes
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A N~EYOJ:k B. ~888
C. CHECK ONE D CITY DlII1i"OWN D VILLAGE
AND We .
SPECIFY. ppUlger
D. STREET ADDRESS 16 Brown Road ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? D
McOr1 / Q&
12580
YES Q;NO
~9G8
13.B. DATE OF BIRTH
13. A. AGE 3&
14. EMPLOYMENT
A. USUAL OCCUPATION HOUlWMe
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH ~~Y(;"
16. FATHER
A. NAME Manuel Quezada
B. COUNTRY OF BIRTH Ecuador
17. MOTHER
A. MAIDEN NAME Res. Remon
B. COUNTRY OF BIRTH Ecu"r
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
D
D
D
o 0 0
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
D D
D D
D D
D D
o legal impediment exists
1ST
2ND
3RD
4TH
I, being duly sworn, depose and s
as to my right to enter into the
21. SIGNATURE OF GROOM
23. SUBSCRIBED AND SWORN T
SIGNATURE OF TOWN OR CITY C DATE
This license authorizes the marriage in New York bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wi I New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D 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)
SIGNATURE ~ -
MAILING ADDRESS
20 .
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TAT
27. TYPE OF CEREMONY
o D RELIGIOUS
9 D OTHER, SPECIFY
1~~IL
12 252004
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT~~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
D CITY OF D TOWN OF ~ILlAGE 0:'" ~ J1.
OSPECIFY 1AJ~,~,tf4 ~
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
22. SIGNATURE OF BRIDE ~
.~
TIME
MONTH
YEAR
MONTH
YEAR
TE 1012612004
10:55 ~~ 10
ZIP
'Z1
SIGNATURE ~ ·