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J COllNTY
CITY/TOWN
DISTRICT
NUMBER
REG ISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
.8m J TamIBr SURNAME
FIRST
I"
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y,I
nutd--r-
WappInger
1388
82
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
o&Iva L I~SURNAME
1. A. FULL NAME
11. A FULL NAME
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Tamln
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER OS:Z"...9352
12. RESIDENCEA. ~nr)Vrx:k B.~
C. CHECK ONE 0 CITY 0 ~WN 0 VILLAGE
AND \....
SPECIFY y..PPI1ger
D. STREET ADDRESS 9 stelnbeus Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES 0"'0
13. A. AGE 3i 13.B. DATE OF BIRTH MotA1 / D1~ /1ii8
14. EMPLOYMENT
A. USUAL OCCUPATION Ditlt Aid
B. TYPE OF INDUSTRY OR BUSINESS V.I. 8I:aIheIs MedaII
15. PLACE OF BIRTH 11_... D.... "'" ·
~IFNOTUSA)
16. FATHER
A. NAME .&.ntaRia lnac:ente Talenlina
B. COUNTRY OF BIRTH Peru r' - J
17. MOTHER '-,
A. MAIDEN NAME P.M. VIM Ceeeres
B. COUNTRY OF BIRTH Peru
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
000
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
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
o
o
<
117..52008045
2. RESIDENCE A. "~ff Vade B. (~
C. CHECK ONE 0 CITY 0 oj/OWN 0 VILLAGE
AND
SPECIFY HgbI8nd
D. STREET ADDRESS 852 ~ de 44155 AI:lt. 1
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE?
3. A. AGE 45 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Faad SeNice SupeAli8ar
B. TYPE OF INDUSTRY OR BUSINESS ilBII8r BmIbeIS Medall
5. PLACEOFIillRTH~Y_
6. FATHER
A. NAME Tham_ Tomlin
B. COUNTRY OF BIRTH UAIttd KlngdCJm
7. MOTHER
A. MAIDEN NAME Miry RII~
B. COUNTRY OF BIRTH U S ^
B. NUMBER OF THIS MARRIAGE 2
ZIP 12528
o YES DtIIo
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9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
100
B. HOW DID LAST MARRIAGE END? (3) 0 II\1ORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? .. ~ / tilfWWII
MONTH DAv-'" Y~
D. ARE ANY FORMER SPOUSE(S) ALIVE? D.S 0 NO
10. 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
0IIZI1_ PousIhkMPIIe. NI\-: York
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK" DATE
This license authorizes the marriage in New York St person authorized by New York
Relations Law ~11 to perform marriage ceremonies withi New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used onl for the purpose of a second or subse uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
Domestic
~
{ SEAL }
"-v-I
NAME (PRINT)
SIGNATURE ~-
MAILING ADDRESS
TIME
MONTH
YEAR
MONTH
YEAR
AM
05
28
at
28 2003
~~~R~:RT~~~ 10~~~~N~EEtf. 26. SOLEMNIZATION OCCURRED
SONS NAMED ABOVE ON THE AY
DATE AND AT THE TIME AND
PLACE INDICATED.
27. TYPE OF CEREMONY
DO RELIGIOUS 1 ~ CIVIL
9 0 OTHER, SPECIFY
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF )i( TOWN OF 0 VILLAGE OF
SPECIFY I{)rf'PNt/<9.E1oL
28. PLACE WHERE MARRIAGE OCCURRED
NAME (PRINT) ,
SIGNATURE ~/