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COUNTY DutdvJss
CITYfTOWW Wappll'\g<<
~~J~~c; 1 gaa
~5~lgJ~R 91
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Frederick I -
MIDDLE . .~RENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~D'il A.. Miran~RENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1 ~ ~ ~12
D. SOCIAL SECURITY NUMBER -~~--
2. RES.IDENCEA. ~VorlC. B. nllt~
"(m'T~ ~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND 'A.....
SPECIFY .w.pplnger
D. STREET ADDRESS 25 T090' HII ROId ZIP 12590
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r!'t NO
3. A. AGE ;t~ 3B. DATE OF BIRTH Mm / Ql / ~JU1
4. EMPLOYMENT
A. USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS ~ Bowes
5. PLACE OF BIRTH ~1~~~R~l~
6. FATHER
A. NAME Antonio I f1P9
B. COUNTRY OF BIRTH Dominican Republic
7. MOTHER
A. MAIDEN NAME Amedee Duren
B. COUNTRY OF BIRTH Domlnl08n R~blle
8. NUMBER OF THIS MARRIAGE 2
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE I ~
(OPTIONAL - SEE REVERSE) nnn ~a ~1 Q
D. SOCIAL SECURITY NUMBER ~~~--
12. RESIDENCE A. NP-IN Vork: B. DlJt~
.....,-mm ~
C. CHECK ONE 0 CITY [JI'TOWN 0 VilLAGE
AND 'A.... .
SPECIFY ~w.pplrver
D. STREET ADDRESS 25 Top 0' HII Road ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE 3fI 13.B. DATE OF BIRTH M /m J(a7A
MONtH ""m. Y '"YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION R~onist
B. TYPE OF INDUSTRY OR BUSINESS PotV'ticeepsle Med. Group
15. PLACE OF BIRTH aranx New Vork .
(CITY, STA'tElCOUNTRY IF NOT USA)
16. FATHER
A. NAME Emesto Miranda
B. COUNTRY OF BIRTH PuArto Rloa
17. MOTHER
A. MAIDEN NAME Mlnerv-a Beta~ In
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 11 / 17 / ~
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
11/17f1<<1J ~ NAwYMt
DEATH
o
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
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Ci
21. SIGNATURE OF GROOM ~
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23. SUBSCRIBED AND SWORN TO BEF RE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York S e of the bride and groom named above by any person au orized by New York Domestic
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 pu ose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Gloria
TIME MONTH YEAR
SEAL SIGNATURE ~
MA~\1d1~ R AM
"'-v-I STREET ZIP 01:12PM 08
~~~R~:RT~~ IO~O!r~~N~Z:~ 26. SOLEMNIZA 28. PLACE WHERE MARRIAGE OCCURRED
SONS NAMED ABOVE ON THE TIME 1 0 CIVIL NEW YORK },. ~.~1. "VI
DATE AND AT THE TIME AND A. STATE B. COUNTY (..!~ '}t.fU4
PLACE INDICATED.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN o~ GYVIL~ &
SPECIFY (j)~
NAME (PRINT)
SIGNATURE ~
ZIP
31. WITNESS TO ~EMONY
NAME(PRINT)~~ t~
SIGNATURE ~ . C j)