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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 ~
