114
>-
z
w
'"
w
CD
o
...J
:::l
o
I
'" .
Z
o
;::
<(
0::
>-
'"
C3
w
II:
w
"
<(
ii'
0::
<(
::;;
u.
o
w
>-
<(
o
u:
;::
0::
W
o
w
0::
w
I
;:
'"
'"
w
0::
o
o
<(
>-
u.
U
w
"-
'"
Z:::i:z
~~2 w
~~~ ....
>-WZ <(
gJd;iJ ()
~~8 i!
Z- -
n~~ t-
iEo", a:
0>->- W
Uj:J!C5 ()
b~~
Z::::i~
COUNTY Dutchess
CITYrrOWN Wappnger
.~[j'J~~c~ 1368
~5~~J~R 114
STATE OF NEW YORK
DEPARTMENT OF HEALTH
A.fFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
AnaeJ Fiaueroa
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
NatMha Natelli Wllianul
MIDDLE CURRENT SURNAME
1. A FULL NAME
11. A. FULL NAME
FIRST
"-
N
8. BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) n~7Q.9415
D SDCIAL SECURITY NUMBER UUU"'
2 RESIDENCE A. N Y B Oranae
(STATE) . (COUNTY)'
C. CHECK ONE 0 CITY ~TOWN 0 VILLAGE
~~~CIFY Newburgh
D. STREET ADDRESS 16 Innis Avenue
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Wlli8nul
(OPTIONAL - SEE REVERSE) #Y71 a.e a.e72
D. SDCIAL SECURITY NUMBER ML_~
12. RESIDENCE A N Y B. Ulster
(STATE) (COUNTY)
C. CHECK ONE 0 CITY rYrOWN 0 VILLAGE
~~~CIFY Marlboro
D. STREET ADDRESS 17 LueI Ann Ortve ZIP 12542
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES rr/ NO
13. A. AGE 27 13.B. DATE OF BIRTH M~H /1~t -"1'~l~
14. EMPLOYMENT
A. USUAL OCCUPATION Microbiologist
B. TYPE OF INDUSTRY OR BUSINESS Y 0 H Sdentlllc. Inc.
15. PLACE OF BIRTH S81nt ~. Grenec:18
(CITY, STAIDCc;~~~Y;F NOT USA)
16. FATHER
A. NAME Leonard Harold Wiliams
B. COUNTRY OF BIRTH Guyana
17. MOTHER
A. MAIDEN NAME ~n Sybil st.. lotM
B. COUNTRY OF BIRTH Grenada
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
12550
YES 'l'! NO
/ 1978
YEAR
ZIP
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
12 /02
MONTH DAY
3. A. AGE 24
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Loss Prevention Officer
B. TYPE OF INDUSTRY OR BUSINESS GaP. Inc.
5. PLACE OF BIRTH Bronx. New Yark
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Angel A ~eroa
B. COUNTRY OF BIRTH Puerto Rico
7. MOTHER
A MAIDEN NAME G10rta M. Padlla
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVO&CE CIVIL ANOLMENT
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID 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, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
0::
W
CD
::;;
::>
Z
Cl
Z
<(
>-
w
W
0::
I-
if)
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, th
as to my right to enter into the marriage
21. SIGNATURE OF GROOM ~
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 D
o 0 4TH 0 0
ewy knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
ZFh ~ 22. SIGNATURE OF BRIDE ~ j 7J '3J~~
E CURR T NAME' .. USE CURRENT NAME
DATE
08I27Q003
by New York Domestic
w
en
z
w
()
::::i
YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DA TE AND AT THE TIME AND
PLACE INDICATED.
STATE
27. TYPE OF CEREMONY
RELIGIOUS 1 ~VIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. CO=-~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF !!'VILLAGE ~_ II
SPECIFY tAhtf'f' ,,:;;6,,.tf& ~
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~