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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Joshua D. &Mona
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wal)l:llnaer
~~J~~~T 1368
~Q~~J~R 108
1. A. FULL NAME
FIRST
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B. BIRTH NAME, IF DIFFEIjENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 061 ~Dn2138
D. SOCIAL SECURITY NUMBER -OJU"'
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY c1'TOWN D VILLAGE
AND Wa
SPECIFY ppinger
D. STREET ADDRESS 24 BowdoIn LIne
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
12 /20 /1974
MONTH DAY YEAR
3. A. AGE 29
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION LandlcaDina
B. TYPE OF INDUSTRY OR BUSINESS ChoIIYwood Llndsceplng
5. PLACE OF BIRTH Beacon. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Dennis SUIsona
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Nsnqt Wood
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, t
as to my right to enter into the marria
21. SIGNATURE OF GROOM ~
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
~
FROM THE BRIDE
Damaris Hernandez
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Pieo
C. SURNAME AFTER MARRIAGE SuIsonR
(OPTIONAL. SEE REVERSE) 1 ~ ~ A~~~
D. SOCIAL SECURITY NUMBER _~~
12. RESIDENCE A. Nf!.w York B. Dlltmess
(WT1t)" (~)
C. CHECK ONE D CITY Dl"rOWN D VILLAGE
~~CIFY Wappinger
D. STREET ADDRESS 24 BowdoIn LIne ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES ~ NO
13. A. AGE ?II 13.B. DATE OF BIRTH 03 /?ny -1Q7~
MONTH -riX\ ~
11. A. FULL NAME
14. EMPLOYMENT
A. USUAL OCCUPATION Production Support
B. TYPE OF INDUSTRY OR BUSINESS Goldman Sachs
15. PLACE OF BIRTH Ponce Duerto Rica
(CITY, STAT~UNTRY IF NOT USA)
16. FATHER
A. NAME Jose Enrique Pieo
B. COUNTRY OF BIRTH Puerto Rica
17. MOTHER
A. MAIDEN NAME IvJa Margarita Hernandez
B. COUNTRY OF BIRTH Puerto RIM
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 01 / 12 / ~
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
01/1212OD4 ~I NAWYork
DEATH
o
rY'
22. SIGNATURE OF BRIDE ~
23. SUBSCRIBED AND SWORN TO B
SIGNATURE OF TOWN OR CITY
This license authorizes th rriage in New York tate of the. bride and groom named above by any person authori.zed
Relations Law ~11 to perfor::7marriage ceremonies W in New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
1IIl If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
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TIME
MONTH
YEAR
DATE 08I24f2004
Falls NY 12590
WN TATE
27. TYPE OF CEREMONY
YEAR 0 D RELIGIOUS
TITLE
DATE
NI
NAME (PRINT)
SIGNATURE ~
AM
02:33 PM
08
ZIP
1~IVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN;:D~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ OF D TOWN OF D VILLAGE OF
SPECIFY ,ge.A~
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STATE