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COWNTY Dutchess
CITYfTOWN Wappinger
~~J~kc~ 1388
~5~~~R 158
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
M~ A. Rqj~RENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Clara Luz Mixco
MIDDLE CURRENT SURNAME
1. A. FUll NAME
11. A. FUll NAME
FIRST
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) ~ ""'" "5~
D. SDCIAL SECURITY NUMBER Y!.L. ~~-~
2. RESIDENCE A. ~.rDrk B. ~ns
C. CHECK ONE 0 CITY [JI'TOWN 0 VILLAGE
~~CIFY For. Hills
D. STREET ADDRESS 87-04 SelfrIdge street
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Mixco . Rq.
D. sJ~:~I~~C~LRi~E~U~~~RSE) 617.21.3282
12. RESIDENCE A. New York: B. DlIlchess
~m'" (~NTY)
C. CHECK ONE 0 CITY ~OWN 0 VILLAGE
AND p_ uooh~
SPECIFY .......~e
D. STREET ADDRESS 1..}ttJ Road ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES r::I NO
13. A. AGE 77 13.B. DATE OF BIRTH n4 /14 AQ81
MONTH DAY YEAR
ZIP 11375
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES r!I NO
~ /"Je / y1W1
3. A. AGE 32
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Cor&truction
B. TYPE OF INDUSTRY OR BUSINESS M. T. A
5. PLACE OF BIRTH IbA~.. CaI(MYthla
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Jor~ Enrique Rq.
B. COUNTRY OF BIRTH Colombia
7. MOTHER
A. MAIDEN NAME Amande Beltran
B. COUNTRY pF BIRTH CdOlf'bll
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION student
B. TYPE OF INDUSTRY OR BUSINESS D. C. C.
15. PLACE OF BIRTH ~A"'IVfI'\. SAn SAlvador
~YIFNOTUSA)
16. FATHER
A. NAME Oscar Alberto Mixco Aviles
B. COUNTRY OF BIRTH B Salvador
17. MOTHER
A. MAIDEN NAME Clara L.uz BerrIos
B. COUNTRY OF BIRTH e Salvador
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
o 0
o 0
o 0
o 0
provided is true and that I declare that no legal impediment exists
22. IGNATUREOFBRIDE~' ~~"
~RENTNAME -
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
o
o
o
o
o
23. SUBSCRIBED AND SWORN TO BEFOR E 11/17'~
SIGNATURE OF TOWN OR CITY CLER ~ DATE - ----~
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 Ne ork State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the urpose of a second or subse uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-v-'
NAME (PRINT)
YEAR
YEAR
TIME
MONTH
AM
01 :5ErM
11
18
STR ET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
2B. PLACE WHERE MARRIAGE OCCURAED
A. STATE NEW YORK B. COUN-a.lJ~Jr~_
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF~OWN OF 0 VILLAGE OF
SPECIFY LA.) () 110/' 11 (
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~