016
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MMftrk A. ChU~aENT SURNAME
1 ST 08/2111995 Suff.oIk Co., New Y or.k DO; D 1 ST 10125/2001 \Nestdlester Co., N Y D DO;
2ND 1012512001 Westchester Co, N Y DO; 0 2ND D D
3RD D 0 3RD D D
4TH D D 4TH 0 D
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is tru~that I declare that no legal Impediment exists
as to my right to enter into the marria state. C' 1 (~
21 SIGNATURE OF GROOMJi 22. SIGNATURE OF BRIDE" ..... ~ <0 ~ \:
. USE CURRENT NAME
23. ~~~;~~~DO~N,oO~~O~~ 6~8g~~~~E DATE 03l3Ol2OO4
This license authorizes .the marriage in New York State 0 the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D 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
COUNTY 01 dChp.c;~
CITYfTOWN Wappinger
~~J~fRT 1368
~G~~J~R 16
1. A. FULL NAME
FIRST
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SDCIAL SECURITY NUMBER 073-80-?ln 4
2. RESIDENCE A. hi v B nl Jt,.h-.CL-
[ST1iTE) ~
C. CHECK ONE D CITY [lITOWN D VILLAGE
AND
SPECIFY \M:ippingP-r
D STREET ADDRESS '2 I-IAcl(II}MAclf I-I~g~ Rna6 125M
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES [Ji'NO
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B. HOW DID LAST MARRIAGE END? (3) [llt\IVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 10/?5 / ?M1
MONTH OAf!" ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? D'llI'Es D NO
1D. 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
38. DATE OF BIRTH
3. A. AGE 35
4. EMPLOYMENT
A. USUAL OCCUPATION Mectlenic
8. TYPE OF INDUSTRY OR BUSINESS VVblte Plains BtlS Co.
5. PLACE OF BIRTH ~I~NT~~ IDttIes
6. FATHER
A. NAME Trevor ChI 109
B. COUNTRY OF BIRTH 'amalea. West Indies
7. MOTHER
A. MAIDEN NAME Flavia Smith
B. COUNTRY OF BIRTH Jamaica, ~!est Indies
B. NUMBER OF THIS MARRIAGE 3
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
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FROM THE BRIDE
11. A. FULL NAME FIRST ~!i' Elena RgJilNT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Rayo
c. s~~~~~(Mr~~~t':e~~SE) Rayg
D. SOCIAL SECURITY NUMBER 133--82 <15Q1
12. RESIDENCE A. ~S't.TE) B. \"l~ester
C. CHECK ONE D.;CITY D TOWN D VILLAGE
AND u&.it nJ -
SPECIFY "Vile rlBlnst
D. STREET ADDRESS 255 Centrallwe A.pt 2 ZIP 10606
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? o,;yES D NO
MOQa / ~ /1~
13. A. AGE 41
14. EMPLOYMENT
13.8. DATE OF BIRTH
A. USUAL OCCUPATION Bus Attendant
B. TYPE OF INDUSTRY OR BUSINESS Boces Transportation
15. PLACE OF BIRTH ~os;;~)
16. FATHER
A. NAME Luis Rayo
B. COUNTRY OF BIRTH Colombia
17. MOTHER
A. MAIDEN NAME Ugla Momeya
8. COUNTRY OF BIRTH Colombia
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) D OJI!\VORCE (3) 0 ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 10/ ")5 / ")M1
MONTH D-';; ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? DIltIES 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
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
ZIP
03
31
2
05
29 2004
2B. PLACE WHERE MARRIAGE OCCURRED
1KCIVIL
A. STATE NEW YORK B. COUNTY
itJE5/~/lE.sTa
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF XTOWN OF D VILLAGE OF
SPECIFY P1 '7; j? I ~/J /V' /
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SIGNATURE ~