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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
RriA" U ~ntn
MIDDLE CURRENT SURNAME
] COUNTY Dutchess
CITYITOWN W.pinger
~[fJ~~~T 1368
~5~~l~R 44
1, A. FULL NAME
FIRST
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 117_R8-7910
2. RESIDENCE A. ~.:f) Vnrlr B. ~prn
C. CHECK ONE 0 CITY MOWN 0 VILLAGE
~~~CIFY Cold Sprirtg
D. STREET ADDRESS 71 FA!d MftllntAi" R()~d
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 20 3B. DATE OF BIRTH
DYES (]III'NO
ZIP
10516
4. EMPLOYMENT
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A. USUAL OCCUPATION C-:Ar:pfl!ntfl!r
B. TYPE OF INDUSTRY OR BUSINESS I-iome Depot
5. PLACE OF BIRTH (~s;.~_N~qm
6. FATHER
A. NAME HIJ9'I' ~ntft
B. COUNTRY OF BIRTH EI Salvador
7. MOTHER
A. MAIDEN NAME Ana "gudo
B. COUNTRY OF BIRTH Equador
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) 0 DEATH
o
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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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 0
2ND 0
3RD 0
~H 0
I, eing uly sworn, depose and say, that to the best 0 my knowledge an
as to my right to enter into the marriagll...state.
21. SIGNATURE OF GROOM ~
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Cbmfina G G~gT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~m:Ni~~~~t~~O~~SE) Co!O
D. SOCIAL SECURITY NUMBER 059-74--9406
12. RESIDENCEA'~E;t'Ork B. ~ess
C. CHECK ONE 0 CITY 0 .Jt)WN 0 VILLAGE
AND W .
SPECIFY ~Jngf!r
D. STREET ADDRESS 1985 Rout~ 9 0 Nodh
ZIP 12590
YES D~o
/1R11
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE 21 13.B. DATE OF BIRTH MJJ~ / ~~
14. EMPLOYMENT
A. USUAL OCCUPATION A5sistant Manager
B. TYPE OF INDUSTRY OR BUSINESS Rainbow (Cothing store)
15. PLACE OF BIRTH (~~I!I,Mmor_
16. FATHER
A. NAME Monc~ Garcia
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Denne Hol'\'Blh
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o 0 0
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 1ST
o 2ND
o 3RD
o 4TH
belief that the information I prOVided is true an
o
o
o
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York bride and groom named above by any person authorized by New York
Relations Law ~11 to perform marriage ceremonies with New 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
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{ SEAL }
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STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATEO.
NAME (PRINT)
SIGNATURE ~-
MAILING ADDRESS
22. SIGNATURE OF BRIDE ~
Domestic
TIME
MONTH
YEAR
MONTH
YEAR
IP
10:5~~
200 06 22 2003
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNrvf):.rfC!;Jtl.r.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF s-'TOWN OF 0 VILLAGE OF
SPECIFY WIJ~'JNC,t1~
04
24
27. TYPE OF CEREMONY
o ~ELlGIOUS
9 0 OTHER, SPECIFY
'"" fl 'r ~t~
DATE -r; / ~-..J
/Vy )')~~
STATE
26. SOLEMNIZATION OCCURRED
TIM M. DAY YEAR
lo;su .:r- 17 (>j
~~~li~'k'~~T ~ e7.J-r~f fJ. ~rt-tl' ;;;.
SIGNATURE ~ )""~ ~ i .
~~G~.DDREf?I!,l PI R '
'tv -e1- ''''' . , E'Clct-I'7
STREET I CITYITOWN
30. WITNESS TO CEREMONY
NAME (PRINT) JJtIl,,~ W1
SIGNATURE ~
DOH-9B (llI9B)
10 CIVIL
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~