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COUNTY Outdt-r
"'::I'rvrrow.>l Wappl~
DISTRICT 1388
NUMBER
~G~~J~R 77
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
"I
.J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
1. A. FULL NAME
iF A. ~ENT SURNAME
11. A. FULL NAME FIRST MM~RII I. N~RRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT MIIYRI
C. S~SM~J~~~~~t~~e~~SE)OGa8iD
D. SDCiAL SECURITY NUMBER 1 CJO..53-2003
12. RESIDENCEA. N.EYodc B. ~B
C. CHECK ONE D CITY o.;rOWN D VILLAGE
AND Wa' .
SPECIFY. pplr:lger
D. STREET ADDRESS 11 l \NbIte Gatt DrIve ZIP
E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D
McOa '/2a
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER Q50..50-1271
2 RESIDENCEA.~yadc B. -Q~~'.lf:11
) 00
C. CHECK ONE D CITY [iJllTOWN D VilLAGE
AND \Ala.
SPECIFY ppngP-r
D. STREET ADDRESS 11 l \NbIte Gate Drtve
12590
YES Q;NO
/.1962
ZIP 12590
D YES c,; NO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 47 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Correction OJIicer
B. TYPE OF INDUSTRY OR BUSINESS Westcbester County
5. PLACE OF BIRTH ~.tlR!;18uX.pr.k
6. FATHER
A. NAME Felix Ocasio
B. COUNTRY 'OF BIRTH Puerto Rico
7. MOTHER
A. MAIDEN NAME AI. Cllor
B. COUNTRY OF BIRTH P-Uerto Rico
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRiAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
13. A. AGE 42
14. EMPLOYMENT
13.B, DATE OF BIRTH
A, USUAL OCCUPATION Teacher A8Biatant
B. TYPE OF INDUSTRY OR BUSINESS Un - Empl~ed
15, PLACE OF BIRTH ~JWfNoY.
16. FATHER
A. NAME sveUm Mavr-a
B, COUNTRY OF BIRTH YupllVlI
17. MOTHER
A. MAIDEN NAME Anna Amlfltano
B. COUNTRY OF BIRTH Italy
18. NUMBER OF THIS MARRIAGE ::2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) OllflIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 02/'" / ~
MONTH OA~ ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? otES 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
1 ' 0 0
B, HOW DID lAST MARRIAGE END? (3) ~IVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 08 / ,..., / "VII\A
MONTH o..-r ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? D.J'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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and
as to my right to enter into the
D DI' 18T 0810712004 Pou;hIeepsle. Ne\.... York D.; D
D D 2ND 0 D
D D 3RD D D
D D 4TH D D
st of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ . (Y) llM. ()... ~ t
USE CURRENT NAME
02I18f.2004 ~l t.... York
w
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W
o
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23. SUBSCRIBED AND SWORN T BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE 07/1212004
This license authorizes the marriage in New York State person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within 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
~
{ SEAL }
'-v-'
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
MONTH
YEAR
YEAR
TIME
MONTH
AM
M
09
10 2004
07
13
ZIP
ATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 D OTHER, SPECIFY
~IVIL
26. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~{.,*~5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF D VILLAGE OF
SPECIFY V)D..ffJ' ~.p r-
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
rv"U~_OA 1111OA\