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COUNTY DI p'chescs
CITYITOWN \Nappinger
~~~~~c~ 1 '368
~5~~J~R '33
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Lui%lIfo!ponio I O~-lf(EN~~URNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
1. A. FULL NAME
11. A. FULL NAME FIRST C~~~~iR Ann S'c?~~!e:NT SURNAME
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Snler
c. SURNAME AFTER MARRIAGE I oppJ
(OPTIONAL. SEE REVERSE)
D. SDCIAL SECURITY NUMBER ORR-5R-9fiR7
12. RESIDENCE A. N v B Dl1tr.h~~
(stATE) (COUNTY)
C CHECK ONE 0 CITY O"","OWN 0 VILLAGE
AND W .
SPECIFY 8pp1nger
D. STREET ADDRESS 395 All Angels Hill Road
FIRST
8 BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SDCIAL SECURITY NUMBER 584-02-7180
2 RESIDENCE A. f\J V B n.ltr.bP.Cl.c::.
. [SThTE) . [COlJNl"Y'l
C. CHECK ONE 0 CITY [],frOWN 0 VILLAGE
AND
SPECIFY W~ppintrr
D STREET ADDRESS 39~ All Angel~ Hill Road
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13.B. DATE OF BIRTH
ZIP 12590
YES D'" NO
/196"
YEAR
ZIP 12590
o YES cYNO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
MO~Tl / Q~
3. A. AGE 44
4. EMPLOYMENT
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Medi~1 Rilling Supervisor
B. TYPE OF INDUSTRY OR BUSINESS Hudson Vall~ Hasp. Cntl
15. PLACE OF BIRTH Bronlt New Yark
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME I nllie:: ~n1er
B. COUNTRY OF BIRTH Puerto RI~
17. MOTHER
A. MAIDEN NAME Dons Santiago
B. COUNTRY OF BIRTH pll~"n RiN\
18. NUMBER OF THIS MARRIAGE 2
13. A. AGE 38
MON
....
:;
<(
c
A. USUAL OCCUPATION Syclter.nc::. AnJilI~t
B. TYPE OF INDUSTRY OR BUSINESS Healt\'l 8< Hnc;pite1c;: Cnrp
5. PLACE OF BIRTH gR.~cruMM~o~&r
6. FATHER
A. NAME Luis Antonio laPP? Sr
B. COUNTRY OF BIRTH PII~rtO Rico
7. MOTHER
A. MAIDEN NAME MiAel\'a Garda Natal
B COUNTRY OF BIRTH Puerto Rico
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
B. HOW DID LAST MARRIAGE END?
(3) 0 ANNULMENT
/ /
YEAR
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) 0 ~VORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 01/ 12 / 1998
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 V\:s 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
1 ST 01112/1998 Broro< (':0 . New Y nrk 0
~D 0
3RD 0
4TH 0
ief that the information I provided is true a1 tha: I /:~Iare. that no.'-ral impe ,.'
22. SIGNATURE OF BRIDE ~. 1. 'iU..Aj,t (J:, "
. USE CURRENT NAME
o
o
(3) 0 DIVORCE
DEATH
o
(2) 0 DEATH
C DATE LAST MARRIAGE ENDED?
MONTH DAY
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
w
en
z
w
()
::i
1ST 0 0
2ND 0 0
3RD 0 .....0
~ 0/
I, being duly sworn, depose and say, that 10.'t~est of my knowledge pr1d
as to my right to enter into the marriag~ y.-
21. SIGNATURE OF GROOM~ .,,,..-y'/ - .---- A
23. SUBSCRIBED AND SWORtffifB~;ORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of th bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE 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
by New York Domestic
DATE
04f21f2004
~
{ SEAL }
'-.,-I
YEAR
YEAR
TIME
MONTH
AM
ZIP 01 :44'M
1~
04
22
20 2004
28. PLACE WHERE MARRIAGE OCCURREn__ .
A. STATE NEW YORK B. COUN1tlf>U 1L'J4t?J
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF . lR"VILLAGE ~ JI
SPECIFY c()AfPP;d7' >>-glf!!1f::j
STRE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICA T
<:..",
29. OFFICIANT
NAME (PRINT)
SIGNATURE
DOH,98 (11/98)
SIGNATURE ~