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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
COUNTY Dut~
CITYfTOWN Wappinger
~~J~f~ 1388
~5~~l~R 85
1. A. FULL NAME
.kwtpb R .
MIDDLE ~RRENT SURNAME
FIRST
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1~ ~,/I8A-
D. SDCIALSECURITYNUMBER -~-~
2. RESIDENCE A. NAIl Vork: B. Anvliv
~Ei'" ~
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY Bronx, New York
D. STREET ADDRESS 1927 M L K Blvd.. AP- 4 A ZIP 10453
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
MO~/:m /1158
3. A. AGE 34
38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Personal Trainer
8. TYPE OF INDUSTRY OR BUSINESS EqJinox
5. PLACE Of EllE\.lH ~~~IJ,R~ X~
6. FATHER
A. NAME Julio RQjBs
B. COUNTRY OF BIRTH Dominican R~bllc
7. MOTHER
A. MAIDEN NAME LJ Idle Cordero
B. COUNTRY OF BIRTH DominiCAn Rep.I~lc
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
8. HOW DID LAST MARRIAGE END? (3) c!' DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 05 / 30 / 20Qg
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
MI'V\I'XV'R DominiCAn ~""I~C r!I
DEATH
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STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
~
~..v~ 3
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kathleen A WA7ard
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT \NAlhrnoIr
C. SURNAME AFTER MARRIAGE Rq;.
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER Q89.~RQ25
12. RESIDENCE A. N Y B. nllt~
(STATE) (COUNTY)
C. CHECK ONE 0 C1TY [JI'TOWN 0 VILLAGE
AND Wa .
SPECIFY ppnger
D. STREET ADDRESS 54 Scott DrIve ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
M /05 ,;(95."
MON'l'H DAY YEAR
11. A. FULL NAME
13. A. AGE 47
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION X-~ Technician
8. TYPE OF INDUSTRY OR BUSINESS M. DnI7AnsI(y. M. D.
15. PLACE OF BIRTH Manhattan New York
(CITY. STATElCOUN~RY IF NOT USA)
16. FATHER
A. NAME William Walbrook
8. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Irene Roberts
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) c1'DlVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 06 / 26 / 2000
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
MI?AJ'X'IM Pou~~f!l, New York:
DEATH
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and S
as to my right to enter into the ma
o 1ST
o 0 2ND
o 0 3RD
o 0 4TH
nowledge and belief that the infDrmation I provided is lr
21.
23.
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{ } NAME (PRINT)
SEAL SIGNATU
MA~~f
'-.,-I STREET
I CERTIFY .HAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
DATE CflICJ7I2OO3
Falls NY 12590
OWN STATE
27. TYPE OF CEREMONY
D 0 RELIGIOUS
9 0 OTHER, SPECIFY
Yor Domestic
TIME
MONTH
YEAR
ZIP
09:24~~ 07
~VIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNT~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF Jt("TOWN OF 0 VILLAGE OF
SPECIFY Loo ? f I tt.j~ r
ZIP
31. WITNESS TO CEREMONY
"M'I"'ND :~~~~R~k
SIGNATURE~ W"f!""'V-~