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048 I- Z W en W 1Il Cl ...J ;::J 0 I en Z 0 8 ;:: " 0:: ~ Ii; a (! W 0:: W 0) Cl " .f! a: 0:: i " ::; u- 0 W I- m " II Ii: ;:: 0:: W II W 0:: W 0:: I W ~ 1Il en ;:; en ::J W Z 0:: 0 Cl Z Cl " " 0- > W W U- 0:: 0 0- W en "- en W (J) Z W (.) :J ~~~ W I-~I- .... ~~~ '" I-WZ - ~d~ (.) ~~g rL z- i3~~ i= :toen a: 01-> W w~C3 (.) 5~1O z~~ COUNTY CITYfTOWN DISTRICT NUMBER REGISTER NUMBER STATE OF NEW YOHK DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE FROM THE GROOM 0.11""....11........"'.........11 (THIS SPACE FOR STATE USE ONL Y) Dutchess Wappinger 1388 48 L 0 SUPPLEMENTAL FILE FROM THE BRIDE M~[FCime B. ~AME ~ 1. A. FUU NAME ~Andy Lee HazJe MIDDLE CURRENT SURNAME FIRST 11. A. FULL NAME FIRST "- N B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT C. SURNAME AFTER MARRIAGE H~e (OPTIONAL. SEE REVERSE) D. SOCIAL SECURITY NUMBER 612-92-2368 12. RESIDENCE A. tWout vO.... B n. rI-........"S (STATE,U 1 I.... . (COU~-- o CITY 0 TOWN ~ VIL~E WAppngers Falls D STREET ADDRESS 8 Wenlls5 Terrece B BIRTH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL - SEE REVERSE) D. SOCIAL SECURITY NUMBER 2. RESIDENCE A. Nf'!!W Vnrk' B. nutN1E"U ~ (COUNW) C. CHECK ONE 0 CITY 0 TOWN Ii VILIIIIAl3E ~~~CIFY WAppingel"K FallK D STREET ADDRESS 8 Wenll~ TerraM ?Rn.. 76-5394 C. CHECK ONE AND SPECIFY 4. EMPLOYMENT 14. EMPLOYMENT A. USUAL OCCUPATION Fledrir.:al FnginP-P-r B. TYPE OF INDUSTRY OR BUSINESS NoveJl~~ ~m5 5. PLACE OF BIRTH MarllAfta nhln - (CITY,STA'i'8C~) 6. FATHER A. USUAL OCCUPATION Supervisor B. TYPE OF INDUSTRY OR BUSINESS Rite Aid 15. PLACE OF BIRTH (CITY, ~'IF~) 16. FATHER A. NAME Randall .Inhn "'A7le B. COUNTRY OF BIRTH ~ I S A 7. MOTHER A. MAIDEN NAME Sheny L.ynn V.nhem B. COUNTRY OF BIRTH II S A 8. NUMBER OF THIS MARRIAGE 1 9. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT A. NAME Francisco Esquiv-el Bartolome B. COUNTRY OF BIRTH Philippines 17. MOTHER A. MAIDEN NAME HeFFAlnlgllEla Dogllle Lagle B. COUNTRY OF BIRTH Phlllppln. 18. NUMBER OF THIS MARRIAGE ~ 19. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT DEATH DEATH o B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE o (3) 0 ANNULMENT / / 1 o o (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) IX DIVO~ (3) 0 ANNULMENT (2) 0 DEATH C. DATE LAST MARRIAGE ENDED? ,(..,... ,( 04 006 MONTH '1.H-DAY 10 YEAR ItHNI' D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ 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 C. DATE LAST MARRIAGE ENDED? 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 1ST 07/1111* \Mal CalWomla ~.:iJ o 2ND 0 D o 3RD 0 0 o 4TH 0 D nd belief that the information I provided is true and that I declare that no legal Impediment eXists 2. SIGNATURE OF BRIDE ~ -d~~ /~ 23. ~~J;T~~~DJN~o~~06'~ ~'?vBg~~~~E DATE 05f25f.2004 This license authorizes the marriage f the bride and groom named above by any person authorized by New York Domestic Relations Law ~11 to perform marriage ceremonies within N York State. THIS LICENSE VALID IN NEW YORK STATE ONLY. o If checked, this license is to tie used only for the purpose of a second or subsequent ceremony. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS 21. SIGNATURE OF GROOM ~ ~ { SEAL } "-.,-I NAME (PRINT) SIGNATURE ~ - MAILING ADDRESS TIME MONTH DAY YEAR MONTH YEAR AM 05 26 07 ~ 2004 STREET I CERTIFY THAT I SOLEMNIZED THE MARRIAGE OF THE PER- SONS NAMED ABOVE ON THE DATE AND AT THE TIME AND PLACE INDICATED. RELIGIOUS 9 0 OTHER, SPECIFY 10 CIVIL 28. PLACE WHERE MARRIAGE OCCURRED A. STATE NEW YORK B()fj;~.e>5 C. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) ~ITY OF 0 TOWN OF 0 VILLAGE OF SPECIFY f1; ~1 It /I.ee;.5" /e....... 29. OFFICIANT NAME (PRINT) ~;/~~ '/11/0 \f V 11 Lh /ILL /I- A) / ()!:r7!~ STATE ZIP e.v 31. WITNESS TO CEREM NY TITLE DATE NAME (PRINT) SIGNATURE ~