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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Sidnev c. Johnston
MIDDLE CURRENT SURNAME
Ai USUAL OCCUPATION DomEStic Engineer
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH (CITY,~~'F ~)
16. FATHER
A. NAME Carlos Alfredo SaJSI7Sl1r
B. COUNTRY OF BIRTH Peru
17. MOTHER
A. MAIDEN NAME Gricelda Merth, lsebel Gonze1ez
B. COUNTRY OF BIRTH Peru
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DEATH DIVORCE CIVil ANNULMENT
o ,0 0
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
the best 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 ~ . ;J~~'
~
DATE
This license authorizes the marriage in New York Stat of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within ew York State. THIS L.,ICENSE VALID IN NEW YORK STATE ONLY.
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
COUWY
CITY/TOWN
DISTRICT
NUMBER
REGISTER
NUMBER
Dutchess
Wetdnger
1368
45
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) rvvl DC.I\IH:A
O. SOCIAL SECURITY NUMBER '::;:lII~
New York B. Dutchess
(STATE) (COUNTY)
o CITY 0 TOtf!.; 0 VilLAGE
POUahauaA
3 HenrvR08d
2. RESIDENCE A.
C. CHECK ONE
AND
SPECIFY
D. STREET ADDRESS
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 22 3B. DATE OF BIRTH 1d
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION
8. TYPE OF INDUSTRY OR BUSINESS De.pl Of Correction
elmira. New York
(CITY, STATE/COUNTRY IF NOT USA)
DAY
stores Clerk
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5. PLACE OF BIRTH
6. FATHER
A. NAME Sidney Carlton Johnston
B. COUNTR~ OF BI~TH USA
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
nAMrah RAnM r:r~
USA
1
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that
as to my right to enter into the marriag
21. SIGNATURE OF GROOM ~
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{ SEAL}
'-y-I
NAME (PRINT)
SIGNATURE ~
MAILING ~RE P
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
U~I~Eaudia S81~~~T~~~lez
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Johnston
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
New York
(STATE) ....
o CITY 0 TOV1"l
Wappinger
6 Foxhlll Road
12. RESIDENCE A.
C. CHECK ONE
AND
SPECIFY
D. STREET ADDRESS
8. (cou9~
o VillAGE
ZIP 12590
DYES 0 NO';
(W' 198
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
l A. AGE ?~ 13.B. DATE OF BIRTH ru(
MONTH
14. EMPLOYMENT
DEATH
o
B. HOW OlD LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
05J20I2004
TIME
MONTH
ZIP
AM
OZ
10 CIVil
26. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY j):I/'ClI6J
c. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~ VilLAGE OF
SPECIFy'\t't/flfIlAfit!tf' flJlP
31. WITNESS TO
NAME (PRINT)
SIGNATURE ~