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COUNTY Dutchess
CITYrrOWN \" lappinger
DISTRICT v 1I
~~~I~~~R 1368
NUMBER 61
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
-.J
1. A. FULL NAME
11. A FULL NAME
Mar~ F ranccs~miT SURNAME
Joon L Gar~RENT SURNAME
FIRST
FIRST
D-
r:;;
B BIRTH NAME, IF DIFFERENT
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT \lito
C. SURNAME AFTER MARRIAGE ""-fCl"-
(OPTIONAL. SEE REVERSE}-"U ""
D. SOCIAL SECURITY NUMBER 101 5& 1274
B~
o VILLAGE
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER on -64-821 B
B ~C3S
VILLAGE
2. RESIDENCE A. N(~ATE)
C. X~6CK ONE 0 CITY ~ TOWN 0
SPECIFY V,,~ppi"'oer
D STREET ADDRESS 46 Tor Road ZIP
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
Mo~1 / 1~
12 RESIDENCE A. N ;irATE)
C. X~6CK ONE 0 CITY q;TOWN
SPECIFY \}.{appinger
D. STREET ADDRESS 46 Tor Road ZIP 12590
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
MMt '/1Dv 19&1
12-590
YES I;/' NO
/MaG2
3. A. AGE 41
4. EMPLOYMENT
38. DATE OF BIRTH
13. A. AGE 42
14. EMPLOYMENT
13.8. DATE OF BIRTH
W
f-
'"
f-
(/)
A. USUAL OCCUPATION Furniture Bales
8. TYPE OF INDUSTRY OR BUSINESS Futon Store
5. PLACE OF BIRTH aJiQ.T~YY_SAJ
6. FATHER
A. USUAL OCCUPATION Sales Representati'.<<e
8. TYPE OF INDUSTRY OR BUSINESS Uggett Vector Brands
15. PLACE OF BIRTH ijtiQ.~TE~X~~SA)
16. FATHER
A. NAME John Carcia
B. COUNTRY OF BIRTH Puef'kl Rico
7. MOTHER
A. MAIDEN NAME Sarah Cruz
8. COUNTRY OF BIRTH Puerto nico
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. NAME Joseph MamA \ Ijto
B. COUNTRY OF BIRTH USA
17. MOTHER
A MAIDEN NAME Charlotte Oertolas
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o 0
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
100
B HOW DID LAST MARRIAGE END? (3) D.Jit>IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? ""4 / ... Q / ')nn"
MONTHU I Dit'/'" "'i!J\1'I" I
D. ARE ANY FORMER SPOUSE(S) ALIVE? D,WES 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
(3) 0 ANNULMENT
/ /
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
1ST
2ND
3RD
01/19/2001 Poughkeepsie, N Y
o
o
o
o
o
o
o
21. SIGNATURE OF GROOM'"
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23. SUBSCRIBED AND SWORN TO FORE ME
SIGNATURE OF TOWN OR CITY CLERK'"
This license authorizes the marriage in New York State f the bride and groom named above by any person aut rized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE O~LY.
o 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
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON'
~
{ SEAL }
'-v-I
NAME (PRINT)
MONTH
TIME
MONTH
YEAR
DAY
YEAR
09:01~~
08
16 2004
06
18
ZIP
l~IL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNTY ~S
C. LOCATION OF CEREMONY
(CHECK ONE A/J SPECIFY)
o CITY OF -I TOWN OF D. VIL~AGE OF
SPECIFY E'aS-"