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COUNTY Dut~
CITYfTOWN Wappinger
~~~~~c: 1368
~G~I~J~R 52
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~D~yan QUezMNT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Rncuali .. A.......
~iLl~...opez - L:.R~SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
"-
N
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C S~~~~~JN~r;:~~~t~~e~~spuezadaN/A
D. SDCIAL SECURITY NUMBER
12. RESIDENCE A. N "TATE)
C. CHECK ONE 0 CITY 0 TOWN
~~~CIFY \NA~n~", FAIl.
D. STREET ADDRESS 15_I;Mt MAIn streM Apt 2 ZIP 125M
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? if! YES 0 NO
JiH /2iy 19li
8. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) N/A
D. SOCIAL SECURITY NUMBER -
2. RESIDENCE A. N v B n. ..~
~ATE) ~
C. CHECK ONE 0 CITY 0 TOWN ., VILLAGE
~~~CIFY Wapp~ Fa'''''
D. STREET ADDRESS 15 EMt MAIn strAM Apt 2 ZIP 125M
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? ri! YES 0 NO
MJM / t7v /1R71
B~I
~ VILLAGE
13. A. AGE 23
14. EMPLOYMENT
A. USUAL OCCUPATION Cook
13.B. OATE OF BIRTH
3 A. AGE 26
4. EMPLOYMENT
A. USUAL OCCUPATION C()nIring
B. TYPE OF INDUSTRY OR BUSINESS EcocI R~llrant
5. PLACE OF BIRTH C?c~C:~USA)
6. FATHER
3B. DATE OF BIRTH
B. TYPE OF INDUSTRY OR BUSINESS Family Home
15. PLACE OF BIRTH ~IC_WOT USA)
16. FATHER
A. NAME JI18nlope?
B. COUNTRY OF BIRTH Mexico
17. MOTHER
A. MAIDEN NAME Juana Arellano
B. COUNTRY OF BIRTH Mexico
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
I- A. NAME .Jo!:e Q'lezada
~ B. COUNTRY OF BIRTH EQ I8dor
C 7. MOTHER
It A. MAIDEN NAME LJ IZ Quaada
<( B. COUNTRY OF BIRTH Ecuador
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
o
o
o
B. HOW DID LAST MARRIAGE END? (31 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
/ /
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
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
II:
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1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided iS~ and that I declare that no legal Impediment eXists
as to my nght to enter into the marriage state. 1:>
21 SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~ o9:>e \, ('L \ - ~PL
USE CURR~
23. SUBSCRIBED AND SWORN TO BEFORE ME .
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 by New York Domestic
Relations Law 911 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
OSID1DOO3
DATE
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{ SEAL }
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NAME (PRINT)
YEAR
MONTH
YEAR
TIME
MONTH
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~AGE OF
SPECIFY 1AJAP1'(;Jjfttb ~
09:14 AM 05
PM
02
06
30 2003
ZIP
TAT
27. TYPE OF CEREMONY
RELIGIOUS
N
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
OATE AND AT THE TIME AND
PLACE INDICATED.
1~
.. NAME (f'RINT)
SIGNATURE ~ .
DOH.98 (11/98)
.
SIGNATURE ~