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COUNTY 01 dchess
CITYITOWN Wappinger
~~~:~CRT 1368
~5~I~J~R 64
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~ Bem~Fftllt:lTSURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
K.LI'- LadenttUNT SURNAME
~
1. A. FULL NAME
11. A. FUUL NAME
FIRST
0-
N
B BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~.Jrias
(OPTIONAL - SEE REVERSE'j""
D. SDCIAL SECURITY NUMBER 59()..24.2825
12. RESIDENCE A N ~ATE) B. ~~~
C. CHECK ONE 0 CITY 0 TOWN ~VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 17 Dutchess Avenue ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 'ij/ YES 0 NO
m, /CJ2y ~912
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER 11 s.so..o35O
2 RESIDENCE A. N v B. n.~
(S'tATE) ~
C. CHECK ONE 0 CITY 0 TOWN ., VILLAGE
~~~CIFY Wappingem Falls
D. STREET ADDRESS 17 Dutcbess Avenue ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ri1 YES 0 NO
MO~ / 1l / tw3
3. A. AGE 29
4. EMPLOYMENT
38. DATE OF BIRTH
13. A. AGE 2S
14. EMPLOYMENT
13.B. DATE OF BIRTH
A. USUAL OCCUPATION GenenII Maneger
8. TYPE OF INDUSTRY OR BUSINESS Petco (pet store)
5. PLACE OF BIRTH ~1t-JBX~SA)
6. FATHER
A. NAME Rei_do Benias
8. COUNTRY OF BIRTH Puerto Rico
7. MOTHER
A. MAIDEN NAME y~ Medne
B. COUNTRY OF BIRTH Puerto Rico
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. USUAL OCCUPATION OperaliOAl Manager
B. TYPE OF INDUSTRY OR BUSINESS Staples (store)
15. PLACE OF BIRTH ~~~~ ......ey
16. FATHER
A. NAME Max L.ac:lenhauf
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Jeenne CelumbG
8. COUNTRY OF BIRTH USA
1B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) 0 DEATH
DEATH
o
o
o
o
o
(2) 0 DEATH
8. HOW DID LAST MARRIAGE END? 13) 0 DIVORCE 13) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
o 0 1ST
o 0 2ND
o 0 3AD
o 0 4TH
Y knowledge and belief that the information I provided is true and that I decl
o 0
o 0
o 0
o 0
re that no legal impediment exists
21.
22. SIGNATURE OF BRIDE ~
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23. SUBSCRIBED AND SWORN TO BEFORE
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o 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
by New York Domestic
,-"-..
{ SEAL }
'-v-'
TIME
MONTH
YEAR
MONTH
YEAR
DATE 06104I2OO3
AM
PM
03 2003
06
05
08
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ OF 0 TOWN OF 0 VILLAGE OF
~"'-bit-~~ , -c...
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS ,NAMED ABOVE ON THE
DATE AND AT THE TIME ANO
PLACE INOICATEO.
ZIP
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29. OFFICIANT
NAME (PRINT)