051
11.
N
~ .
w
en
w
III
o
...J
:::>
o
::J:
en
Z
o
~
a:
....
en
a
w
a:
w
Cl
..
~
a:
..
:::;
u.
o
w
....
..
()
u:
>=
a:
w
()
w
a:
w
::J:
~
en
en
w
a:
o
o
..
>
u.
i3
w
11.
f/)
~~~
....~....
~~~
....wz
f/)...J:::;
:::>()W
:::;Cl5
....zen
z-
n~~
tEem
0....>
w~~
5~"'
Z::i~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFADAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
COUNTY .... "'---
CITYflOWN Wappnger
~~J~~~T 1~
~5~~l~R 51
1. A. FULL NAME
M~ T l.oJ5RENT SURNAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 509-1 '3-4628
2. RESIDENCE A.--bfmIYotk B. -Qi~esl
c. CHECK ONE 0 CITY 0 TOWN [jjIIvILLAGE
~~~CIFY Wappin~ J;SIIIIl.
D. STREET ADDRESS 1.4 Fulton strNlt f4P 5 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? rJI'vEs 0 NO
3. A. AGE 28 3B. DATE OF BIRTH MJMI / 6IJ / v1Q75
4. EMPLOYMENIT
A. USUAL OCCUPATION Cook
B. TYPE OF INDUSTRY OR BUSINESS longobardI, Restaurant
5. PLACEOFBIRTH~'~~CO'
6. FATHER
A. NAME Timotp'() Lopez Zar:sJe
B. COUNlTRy'OF BIRTH Mexico
7. MOTHER
A. MAIDEN NAME 8eI#uI ROlli IiRSlso
B. COUNTRY OF BIRTH Mexico
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORC~
C. DATE LAST MARRIAGE ENDED?
(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
I
STATE FILE NUMBER
(THIS SPACE FOR STATEUSE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
WJIWY D. MO~.NT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
c. S~S~~(M,~~~t~~e~~SE)Lapez
D. SOCIAL SECURITY NUMBER 078-48-15Q6
12. RESIDENCE A. N!M(-EYOr:k B. . Q.-.
C. CHECK ONE 0 CITY 0 TOWN ~ILLAGE
~~~CIFY Wappinger:s FIIIIs
D. STREET ADDRESS 14 Fulton street ArJ,.. 5 ZIP 125eO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? [il'YES 0 NO
Mc05 . / QQ "'13i3
13. A. AGE 2S
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION Dietary Aid
B. TYPE OF INDUSTRY OR BUSINESS V_er Sf 01. MecI. ar.
15. PLACE OF BIRTH ~_~~co
16. FATHER
A. NAME Ignlldo MORiIIes GuzmaR
B. COUNTRY OF BIRTH Mexico
17. MOTHER
A. MAIDEN NAME Patrtele MentlAe De Mereles
B. COUNTRY OF BIRTH MeKloo
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that tD the
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM ~
o 0 1ST 0 0
o 0 2ND 0 0
D 0 3RD 0 D
o 0 4TH 0 D
ge and belief that the informatiDn I provided is true a~nd that I decl re that no legal impediment exists
22. SIGNATURE OF BRIDE ~ _ Lk-
CURRENT NAME
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York S and groom named above by any person authorized by. New York Domestic
Relations Law ~11 to perform marriage ceremonies withi New 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
w
en
z
w
o
:J
~
{ SEAL }
'-.,-I
NAME (PRINT)
TIME
06f03Q004 AM
09:47 PM
ZIP
MONlTH
YEAR
MONTH
YEAR
08
04
08
02 2004
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
ATE
27. TYPE OF CEREMONY
o ~ELlGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY nllT'''\..t!O oS
ZIP
31. WITNESS :JEREMONY
NAME (PRINT) S e
SIGNATURE ~
\