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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~MiV' c. 8err~NT SURNAME
23. SUBSCRIBED AND SWORN TO BEFORE ME.
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State
Relations Law ~11 to perform marriage ceremonies within N 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
C,).INTY DutchtSS
CITYfTOWN Wappinger
DISTRICT 1368
NUMBER
~5~~J~R 112
1. A.. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER D51..ft8.- ]Q6&
2. RESIDENCE A. _IYar:k B. 9Ht~8B.
C. CHECK ONE 0 CITY 0 TOWN ~VILLAGE
AND .
SPECIFY VVaPPllgem F.aIJa
D. STREET ADDRESS 17 Creek VI_ Court
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3B. DATE OF BIRTH
ZIP 12580
[l;fES 0 NO
3. A. AGE 27
4. EMPLOYMENT
1.1
A. USUAL OCCUPATION BUlin_. Owner
B. TYPE OF INDUSTRY OR BUSINESS EltdrOAlc:l Auto Seoudty
5. PLACE OF BIRTH ~Blpo
6. FATHER
A. NAME Juan E. SemIna
B. COUNTRY OF BIRTH Puerto RIco
7. MOTHER
A. MAIDEN NAME Cermen D. Gerele
B. COUNTRY OF BIRTH DomlnlceA Republic
B. NUMBER OF THIS MARRIAGE :2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
100
B. HOW DID LAST MARRIAGE END? (3) otllVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? t'II"J./~.. / ~
MONTH W. DA,,"t ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? [)jIIES 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
1 ST CJ:aQ112OO3 CoronIa Ne\,": York
2ND
3RD
4TH
I, being duly sworn, depose an say
as to my right to enter into the mar .
21. SIGNATURE OF GROOM ~
Doll' 0
o 0
o 0
w
en
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,-I'-..
{ SEAL }
'-v-'
NAME (PRINT)
SIGNATURE ~
MAILING ADDRES
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INpICATED.
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
ReEt.lmaFie Y. ~"SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~(M~~rt~~e~~SE)SemlRB
D. SOCIAL SECURITY NUMBER D51-.&Q.-1022
12. RESIDENCEA. NlNfEyerk B. ~
C. CHECK ONE 0 CITY 0 TOWN ~ILLAGE
AND .
SPECIFY Y'l8ppAg818 Falls
D. STREET ADDRESS 17 CrMk: \AM Coult ZIP 12580
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~YES 0 NO
13. A. AGE Zl 13.B. DATE OF BIRTH M01T1 / ~l- ~il5
14. EMPLOYMENT
A. USUAL OCCUPATION Registered NUIII8
B. TYPE OF INDUSTRY OR BUSINESS MoRten... Meet Center
15. PLACE OF BIRTH -g~~ Y_SA)
16. FATHER
A. NAME Daniel Ri\,'."
B. COUNTRY OF BIRTH PueIto Rloo
17. MOTHER
A. MAIDEN NAME Ane Role Mertl".
B. COUNTRY OF BIRTH PuertG RlGG
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o
(2) 0 DEATH
D8Q5QOO3
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
ZIP
09:1o;~
10 24 2003
08
28
ATE
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
l~IVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY ~ II---:J'/
29. OFFICIANT
NAME (PRINT)
ZIP
31. WITNESS TO CEREMONY
. r
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