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COUNTY 01 dche5s
CITY"-OWN Wsppnger
~~~~kc~ 1368
~5~I~J~R 78
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
..;J I "" t ~ riLl:; ...u,,,,cJ:;n
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
.-J
1. A. FULL NAME
MI~~oob Rey~RRENT SURNAME
11. A. FULL NAME
M~998 Rive~lRENT SURNAME
FIRST
FIRST
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 122-64- 3358
2 RESIDENCE A. ~E~ or.k B. Q~esl
C CHECK ONE 0 CITY 0 TOWN [iJJVllLAGE
~~~CIFY WappingerB Fall5
D STREET ADDRESS 14 Flllton street Apt. 2 ZIP 12~
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? [il'YES 0 NO
MO~ / aa / ~:l81
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~~~~~JN~~~~~:~~e~~SE)Rc)'es
o SOCIAL SECURITY NUMBER Q88..68...8782
12 RESIDENCE A N_yoFk B ~
C. CHECK ONE 0 CITY 0 TOWN CV'lllAGE
AND
SPECIFY \f'Jappingel8 Falls
D. STREET ADDRESS 14 Fulton Street Apt. 2 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
13. A. AGE 21 13.8. DATE OF BIRTH MJJ& / OJ. "1983
14. EMPLOYMENT
A. USUAL OCCUPATION SalfJ8 PeFBBA
B. TYPE OF INDUSTRY OR BUSINESS Hershey's Ice Creem
15. PLACE OF BIRTH ~~NttNu~,Fk
16. FATHER
3. A. AGE 2-3
4. EMPLOYMENT
A. USUAL OCCUPATION Student
B TYPE OF INDUSTRY OR BUSINESS Monroe College
5. PLACE OF BIRTH -@W~Y"~SA)
6. FATHER
3B. DATE OF BIRTH
A. NAME Ruben Reyes
8. COUNTRY OF BIRTH Puerto Rlc:o
7. MOTHER
A. MAIDEN NAME Madeline .'wjles
8. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
A. NAME Pedro RiveF8 Jr.
8. COUNTRY OF BIRTH U S ^
17. MOTHER
A. MAIDEN NAME Myrlam Guzman
B. COUNTRY OF BIRTH Pueftc Rico
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
(3) 0 ANNULMENT
/ /
(3) 0 ANNULMENT
/ /
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
MONTH DAY YEAR
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
o 0
o 0
o 0
o 0
pe~iment exists
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, t
as to my right to enter into the marri
21.
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
f my knowledge and belief that the information I provided is true and that 1 declare that no Ie
2. SIGNATURE OF BRIDE ~
~
USE CURRENT NAME
w
en
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::::i
23. SUBSCRIBED AND SWORN T
SIGNATURE OF TOWN OR
This license authorize
Relations Law ~ 11 to P
DATE
of the bride and groom named above by any person authorized by New York Domestic
W York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
e used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
~
NAME (PRINT)
TIME
MONTH DAY
YEAR MONTH
YEAR
AM
11:46pM 0('7
ZIP 'I
1~
12 2004
15
09
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~jZ Jk.I.8
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF ~ILlAGE OF
SPECIFY WAtPtf::JJ~Yl6 ~
NAME (PRINT)
SIGNATURE ~