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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~~W' ~dieg~ENr SURNAME
23. SUBSCRIBED AND SWOR 0 BEF
SIGNATURE OF TOWN OR CITY CLERK" DATE
This license authorizes the marriage in New York St 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 LICENSE VALID IN NEW YORK STATE ONLY,
o If checked. this license is to be used onl for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
COUNTY Dutchess
flT.YrrOWN Weppln~
~~J:~ 1~
~5~I~J~R 32
1. A FUll NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D, SOCIAL SECURITY NUMBER 07o.~5098
2. RESlDENCEA.~m)YOrl<' B, ~
C. CHECK ONE 0 CITY 0 TOWN Cill'l/ILLAGE
~~CIFY ~ppingP-nL J:allR.
D, STREET ADDRESS 8 Creek Vlt!JJN eo.lrt
ZIP 12590
o;vES 0 NO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 31 3B. DATE OF BIRTH
4, EMPLOYMENT
A, USUAL OCCUPATION Debililer
B, T\'PE OF INDUSTRY OR BUSINESS Hudson Vllley VoIlcswlgeR
5. PLACE OF BIRTH ~l,.A~'lT USA)
6. FATHER
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A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME MaFia ZUlma Gwtlerr.
B. COUNTRY OF BIRTH Columbia
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) [JIlbIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 01/ na / iW"IA
MONTH DA'" ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? [)ljlIES 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
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1ST 011OW2OO4 ~*"" Ywk. tle\v York
2ND
3RD
4TH
I, being duly sworn, depos
as to my right to enter int .
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{ SEAL }
'-v-I
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
0;
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STATE FILE NUMBER
(THIS SPACE: FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~!iP I S&ndi!ReNT SURNAME
~
11. A. FULL NAME
FIRST
e, BIRTH NAME (MAIDEN NAME), IF DIFFERENT Cawajal
C. SURNAME AFTER MARRIAGE Quti8lr8Z
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 1 QO..7 4-1586
12, RESIDENCEA. ~E) B, ~~esB
C. CHECK ONE 0 CITY 0 TOWN D.;IItIILLAGE
~~~CIFY Wsppingers Falls
D. STREET ADDRESS 8 Creek VIew Court ZIP Vor.k
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? ~YES 0 NO
McOa / Q2 --'1,.
13. A. AGE 40
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION Kitc:h8n Aide
B. TYPE OF INDUSTRY OR BUSINESS Clthollo ChaFII.
15. PLACE OF BIRTH "'Lr ~"
, A TUBA)
16. FATHER
A. NAME NacianC8RQ CaJlas CBr\~aI
B. COUNTRY OF BIRTH Columbia
17. MOTHER
A. MAIDEN NAME Rosa Marla Muriel
B. COUNTRY OF BIRTH Columbia
lB, NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) DlfllVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 01 / ~. / "V'tt\i:I
MONTH oA'f ifi!lilI!Ii'V
D. ARE ANY FORMER SPOU~E(S) ALIVE? ~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
Q8/1812Q03 New York, New York Dr; 0
o 0
o 0
o 0
declare that no legal impediment exists
TIME
MONTH
YEAR
MONTH
YEAR
TE
06 192004
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY t...+~
c, LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) I
o CITY OF 0 TOWN OF V VILLAGE OF
04
21
NAME (PRINT)
SIGNATURE ..